Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Brookwood Skilled Nursing And Therapy during CMS and state inspections, most recent first.
Two residents with PICC lines did not receive or have documented weekly sterile dressing changes and mid-arm circumference measurements as required by facility policy. One resident lacked physician orders and documentation for PICC line care after insertion, while another had orders discontinued after a hospital transfer and not resumed upon return, resulting in missed dressing changes and measurements. The DON confirmed that standard PICC line care protocols were not followed or documented.
The facility failed to provide timely pain medication for a resident with chronic back pain who reported severe pain, could not tolerate movement, and delayed incontinent care until Tylenol was finally given about 1.5 hours after staff were notified. The facility also failed to consistently assess and monitor another resident with chronic pain, a BKA, and orders for oxycodone, baclofen, and pregabalin; the resident reported ongoing pain, depression related to pain, and that the medication did not help, while the chart lacked consistent pain monitoring.
Residents were not provided a clear option to decline an arbitration agreement during the admission process. An admission packet used a single e-signature for multiple forms, including the arbitration agreement, and staff stated the process could not continue without a signature. Several residents later said they did not know what an arbitration agreement was or that they had signed one, while staff acknowledged uncertainty about the agreement and said residents had to sign to move through admission.
A resident with a PICC line received incontinent care from two CNAs without gowns despite EBP requirements, and there was no precaution sign on the door. In a separate observation, a resident using PRN O2 had a nasal cannula and tubing that were not dated, and the cannula was left hanging on the bed rail without being bagged when not in use; staff and the DON stated the equipment should be bagged and dated to prevent infections.
A resident with chronic pain, muscle spasm, and a right BKA had a care plan calling for pain assessment, documentation, and evaluation of pain interventions, while receiving scheduled oxycodone, baclofen, and pregabalin. Pain assessments showed severe ongoing pain, depression related to pain, and that pain medication did not help, but the chart and MAR did not show consistent pain monitoring. An RN said pain was sometimes noted in progress notes, and the DON acknowledged pain was not being assessed and monitored consistently and that the care plan was not followed.
A resident with COPD and acute pulmonary edema had PRN O2 orders, but staff observed the nasal cannula and tubing without a date and left hanging by the bedside instead of being bagged when not in use. The resident used oxygen as needed, and the LPN, IP, and DON all confirmed the tubing and cannula should be dated and bagged to prevent infections.
A resident with insulin-dependent type 2 diabetes mellitus experienced a hypoglycemic crisis due to the facility's failure to administer Glucagon as ordered. Despite blood sugar readings below 70, nurses did not provide the necessary intervention, leading to the resident's hospital admission with a critically low blood sugar level.
A resident with a urinary tract infection and pneumonia had follow-up lab results showing elevated WBC and Neutrophil levels, but the facility failed to notify the physician. The resident was later hospitalized with severe sepsis and expired. The facility lacked a reliable system to ensure abnormal lab results were communicated to the physician.
The facility failed to notify the physician of abnormal blood sugar levels for two residents with type 2 diabetes mellitus. One resident had multiple instances of elevated blood sugar levels without physician notification, while another had both high and low levels outside the specified parameters without documentation of notification. The DON confirmed the lack of documentation.
A resident with a history of aggressive behavior verbally and physically abused another resident, leading to a deficiency in the facility's ability to protect residents from abuse. Despite multiple incidents of disruptive behavior, the facility failed to implement effective interventions to manage the resident's actions, resulting in ongoing risk to other residents.
The facility failed to report an incident of resident-to-resident abuse to the OSDH, as required by their policy. During the incident, one resident verbally abused another, who then threw magazines at the first resident. Despite the act of physical aggression, the facility concluded it was not reportable, citing the nature of the residents' relationship. This decision was contrary to the facility's policy, which mandates reporting all reasonable suspicions of abuse.
A resident with possible osteomyelitis missed multiple doses of prescribed Cipro, and the facility failed to notify the physician as required by policy. The resident had diagnoses including right BKA, diabetic ulcer, and diabetes mellitus.
The facility failed to ensure accurate MDS assessments for four residents, including discrepancies in documenting diabetic foot ulcers, incorrect medication administration records, and inconsistencies in communication abilities for a resident with dementia.
The facility failed to coordinate care with hospice for a resident, did not follow physician orders for lab tests for a diabetic resident, and did not administer wound care treatments as ordered for two residents. Additionally, a resident with weight loss was not taken to the dining room for meals as required.
The facility failed to provide ordered pressure ulcer treatment for a resident with chronic non-pressure ulcers and DTI. The resident's dressing was not changed daily as required, leading to an open area with necrotic tissue and drainage observed on the bed pad.
The facility failed to ensure the accuracy of narcotic counts and proper documentation of eight-hour verification sheets. A discrepancy was found in the narcotic count for a resident receiving Oxycodone, and numerous instances of missing signatures on verification sheets were noted, indicating improper shift change documentation.
The facility failed to maintain proper infection control during medication administration, as observed with two CMAs who touched medications with their bare hands and did not follow the policy for handling dropped pills.
The facility failed to ensure that information was offered to formulate an advance directive for a resident admitted to hospice services for senile degeneration of the brain. The clinical record lacked documentation that this information had been provided, and the DON confirmed that the paperwork was still pending.
A facility failed to ensure a clean mattress for a resident, as observed during an inspection. The mattress had brown residue and rings, identified by a CNA as dried urine and feces. The CNA mentioned that mattresses were inspected during linen changes and disinfected twice a week, but the soiled condition indicated a lapse in these procedures.
The facility failed to complete a comprehensive assessment every 12 months for a resident. Despite completing an Admission Assessment and subsequent Quarterly Assessments, an Annual or other comprehensive assessment was not conducted as required. The DON, MDS coordinator, and Consultant RN confirmed the oversight.
The facility failed to ensure proper nail care for a resident with severe cognitive impairment and multiple dependencies on staff for ADLs. The resident was observed with long and overgrown toenails and brown debris under their long fingernails. Despite the facility's policy on fingernail care, staff did not maintain the resident's nails, and an RN acknowledged the need for trimming but did not take action.
The facility failed to secure smoking products for a resident with severe cognitive impairment who required supervision while smoking. Despite the facility's policy, the resident was observed with a lighter on their over-the-bed table on multiple occasions, and the DON confirmed that the smoking policy had not been followed.
Failure to Perform and Document Weekly PICC Line Care and Measurements
Penalty
Summary
The facility failed to ensure that peripherally inserted central catheter (PICC) line dressings were changed and mid-arm circumference measurements were completed and documented every seven days for two of three sampled residents reviewed for PICC line care and maintenance. For one resident, the PICC line dressing was observed to be dated ten days prior to the survey, with no documentation of dressing changes or mid-arm circumference measurements since the line was inserted. There were also no physician orders for PICC line sterile dressing changes or mid-arm circumference measurements found in the medical record. The resident had diagnoses including orthopedic aftercare following surgical amputation and severe protein-calorie malnutrition, and was severely cognitively impaired, receiving IV medications through the PICC line. For another resident, the PICC line dressing was observed to be nine days old, and there was no documentation of mid-arm circumference measurements or dressing changes since the initial insertion, except for one documented dressing change shortly after insertion. The physician order for weekly dressing changes had been discontinued after a hospital transfer and was not resumed upon the resident's return, despite ongoing IV medication administration. The Director of Nursing confirmed that standard orders for PICC line care and maintenance, including weekly sterile dressing changes and documentation, should have been in place and followed for all residents with PICC lines.
Delayed Pain Medication and Inconsistent Pain Monitoring
Penalty
Summary
The facility failed to provide timely pain medication for a resident with chronic back pain who had been admitted from the hospital after a UTI, had a PICC line, and had gone to the emergency room because the back pain worsened to the point that the resident could not ambulate. On 09/16/25 at 5:55 a.m., the resident told a CNA that their back was killing them, that any movement hurt, and they would not allow incontinent care because of the severity of the pain. At 5:57 a.m., the CNA told an LPN that the resident needed a pain pill because they could not move, and the LPN said okay. The resident did not receive Tylenol until 7:31 a.m., while continuing to rub their back and state that it hurt and that Tylenol was not strong enough and they wanted something stronger. The resident’s care plan directed staff to anticipate the need for pain relief and respond immediately to any complaint of pain. The resident had an order for Tylenol 325 mg, 2 tablets every 6 hours as needed for pain. The ADON stated the resident should have received the pain medication once the medication cart keys were taken and that when someone was in pain they should be responded to immediately. The DON stated staff should give pain meds as soon as possible and that an hour and a half was not an acceptable time frame. The resident’s family member also stated pain management was their only concern because they believed the resident was in pain. The facility also failed to consistently evaluate the effectiveness of regularly scheduled pain medication for another resident with chronic pain, muscle spasm, and a right below-the-knee amputation. That resident had orders for oxycodone, baclofen, and pregabalin, and the MAR showed the medications were given as prescribed. However, pain assessments documented pain ratings of 4 to 7 out of 10 and later 7 to 10 out of 10, with the resident reporting the pain was the same, worse, and causing depression. The resident stated the pain medication did not help and denied being regularly assessed or monitored for pain. Staff and the DON stated pain was watched for during rounding and sometimes documented in progress notes, but the chart did not show consistent pain assessment or monitoring, and the DON acknowledged the resident’s pain was not being assessed and monitored consistently.
Residents Not Given Clear Option to Refuse Arbitration Agreement
Penalty
Summary
The facility failed to ensure residents were provided with an option to not sign the arbitration agreement for 6 of 6 sampled residents reviewed for arbitration agreements. The record review showed an undated document titled "An Explanation to the Resident/Family" stating that by signing the admission contract, the resident's electronic signature would be placed on the admission agreement, consent to treat, medical records release form, and the dispute resolution/arbitration agreement. An admission packet revised 11/29/22 showed DocuSign was set up so the resident or resident's legal representative agreed to everything inside the admission packet with just one signature, and the arbitration agreement was included as part of that packet and agreed to upon admission for everyone admitted to the facility. Resident #24, #31, #38, #46, #53, and #96 each signed an arbitration agreement on their respective admission dates. During the Resident Council meeting on 09/16/25, these residents denied knowing what an arbitration agreement was or that they had signed one. The admissions director stated that an electronic signature was used and that the admission process could not continue without a signature. When asked whether it was really an option if the process could not go forward without a signature, the admissions director stated they had not thought about that and did not know the full extent of what an arbitration agreement was. The regional nurse stated residents had to sign to move through the admission process, but that rescinding within 30 days was explained to them. The administrator stated all residents had signed the arbitration agreement.
Failure to Follow EBP and Oxygen Equipment Handling Requirements
Penalty
Summary
Enhanced Barrier Precautions were not followed during incontinent care for a resident with a PICC line. On 09/16/25, two CNAs were observed providing incontinent care to Resident #122 without gowns. Resident #122 had a PICC line in the upper right arm, and the facility policy stated that EBP apply to residents with wounds and/or indwelling medical devices, including PICC lines, with gloves and gown required during high-contact care such as changing briefs or assisting with toileting. A physician order revised 09/10/25 indicated EBP related to the PICC line were to be utilized. During interview, a CNA stated EBP, including gown, mask, and gloves, were to be used for residents on isolation, and the DON stated a tile magnet was to be placed outside the door to indicate precautions, but there was no sign on Resident #122's door. Oxygen equipment was not handled as required for Resident #53. On 09/15/25 and again on 09/17/25, Resident #53 was observed with a nasal cannula attached to an oxygen concentrator, and the tubing and cannula were not dated. On 09/17/25, the nasal cannula was hanging on the bed rail attached to an oxygen concentrator not in use and was not bagged. Resident #53's annual assessment showed intact cognition with a BIMS score of 15, and the resident had diagnoses including acute pulmonary edema and COPD. The resident had a physician order for PRN oxygen at 2 L NC to maintain stats greater than 92% for shortness of breath or distress. Staff interviews confirmed that nasal cannulas should be bagged when not in use and oxygen tubing and cannulas should be labeled with the date they were administered to prevent infections.
Failure to Consistently Assess and Monitor Pain
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention for pain monitoring for one resident with chronic pain, muscle spasm, and a right below-the-knee amputation. The undated care plan stated the resident was at risk for pain, had medication in place, and required pain characteristics to be assessed and recorded, with effectiveness of pain interventions evaluated and compliance, symptom relief, and resident satisfaction reviewed. Physician orders showed the resident was receiving Oxycodone 5 mg every 6 hours for pain, Baclofen 10 mg daily, and Pregabalin 150 mg on Monday, Wednesday, and Friday for neuropathy, and the MAR showed these medications were administered as prescribed during July, August, and September 2025. Pain assessments documented the resident rated pain as high as 7 out of 10 at worst and between 4 and 7 out of 10 at the time of one assessment, with pain reported as the same or worse and depression caused by the pain. A later pain assessment showed pain rated 10 out of 10 at worst and 7 out of 10 at the time of assessment, with pain still reported as the same and depression again reported; the resident also stated the pain medication did not help. Review of the chart and MAR did not show consistent pain assessment or monitoring. RN #2 stated pain was sometimes documented in progress notes and that staff would tell med aides to give a pain pill if it was time, while the DON stated pain monitoring appeared on the MAR only for PRN pain medication, was unsure whether another pain assessment had been completed since the first one, and acknowledged the resident’s pain was not being assessed and monitored consistently and that the care plan was not followed.
Oxygen tubing and nasal cannula not dated or bagged when not in use
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #53. During observation on 09/15/25, the resident was in bed wearing a nasal cannula attached to an oxygen concentrator, and there was no date on the oxygen tubing or nasal cannula. On 09/17/25, the resident’s nasal cannula was again observed hanging on the bed rail attached to an oxygen concentrator, and the tubing and cannula were still not labeled with the date they were administered. The facility policy stated that when this equipment is changed out, it needs to be dated. Resident #53’s annual assessment showed intact cognition with a BIMS score of 15, and the resident’s diagnoses included acute pulmonary edema and COPD. The physician order dated 09/11/25 directed oxygen at 2 L via nasal cannula to maintain oxygen saturation greater than 92% as needed every shift for shortness of breath or distress. The resident stated they used oxygen as needed, and staff confirmed the resident had oxygen orders. The LPN stated oxygen tubing and nasal cannulas should be changed and labeled with the date they were administered, and acknowledged the tubing and cannula were hanging by the bedside, not bagged, and not labeled. The IP stated oxygen tubing and nasal cannulas should be bagged when not in use and labeled with the date to prevent infections, and the DON stated the tubing should be labeled with the date it was administered and the nasal cannula should be bagged when not in use.
Failure to Administer Glucagon for Hypoglycemic Resident
Penalty
Summary
An Immediate Jeopardy situation was identified at a facility due to the failure to properly assess, monitor, and administer medication for a resident with insulin-dependent type 2 diabetes mellitus experiencing hypoglycemia. The resident was admitted with orders for routine insulin administration and blood sugar monitoring, with specific instructions to administer Glucagon if blood sugar levels fell below 70. On a particular day, the resident's blood sugar was recorded at 68, but the nurse did not administer the Glucagon gel as ordered. This oversight was compounded when the oncoming nurse also failed to assess or intervene for the low blood sugar level. Later that morning, the attending physician ordered the resident to be sent to the emergency room after another low blood sugar reading of 49 was recorded. Despite this critical reading, the nurse again did not administer the Glucagon gel. Upon arrival at the emergency room, the resident's blood sugar was critically low at 21, leading to their hospital admission. The Director of Nursing reviewed the records and acknowledged the failure to assess, monitor, and administer the necessary medication during the hypoglycemic crisis.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the physician of a resident's laboratory results that were outside of clinical reference ranges, indicating a deterioration in the resident's condition. The resident was admitted with diagnoses of urinary tract infection (ESBL) and pneumonia and was receiving antibiotic therapy. Initial lab results showed elevated WBC and Neutrophil levels, which were signed off by the physician. However, follow-up lab results showed a significant increase in these levels, but there was no documentation that these results were reported to the physician. The resident was later transferred to the emergency room and admitted to the hospital with severe sepsis with septic shock, pyelonephritis, and C-difficile colitis. Unfortunately, the resident expired in the hospital. The Director of Nursing (DON) reviewed the clinical records and confirmed that there was no documentation to show that the follow-up lab results had been communicated to the physician. The physician also confirmed that they were not informed of the abnormal lab results, which would have prompted immediate medical intervention. The facility's process for reviewing and reporting lab results involved printing results from the lab company's electronic system each morning and reviewing them in a morning meeting. However, there was no system in place to ensure that abnormal lab results were consistently documented and communicated to the physician. This lack of a reliable communication system contributed to the failure to notify the physician of the resident's critical lab results, leading to a delay in necessary medical intervention.
Failure to Notify Physician of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of blood sugar levels outside of the specified parameters for two residents with type 2 diabetes mellitus. Resident #1 had a physician's order to receive insulin and notify the provider if blood sugar levels were between 301-999, with a recheck in two hours. However, multiple instances of elevated blood sugar levels were recorded in December 2024, and there was no documentation indicating that the physician was notified as required. Similarly, Resident #3 had a physician's order to notify the physician if blood sugar levels were between 0-69 or 401-999. Despite several instances of blood sugar levels falling outside these parameters in December 2024, there was no documentation of physician notification. The Director of Nursing reviewed the clinical records and acknowledged the lack of documentation for physician notification for both residents.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by another resident with a history of uncontrolled abusive behavior. Resident #1, who had diagnoses including congestive heart failure and cerebral infarct, was reported to have been verbally abused by Resident #2. An incident report indicated that Resident #2 had yelled at Resident #1, leading to an investigation. Resident #2, who was cognitively intact, had a history of behavioral issues, including yelling, cursing, and throwing objects. Despite these behaviors, the facility did not implement effective interventions to manage Resident #2's actions. Resident #2's behavior escalated over time, with multiple incidents documented where they exhibited aggressive and disruptive behavior. These included throwing magazines at Resident #1, yelling at staff, and attempting to harm themselves. On one occasion, Resident #2 was reported to have entered Resident #1's room, demanded attention from staff, and physically assaulted a CNA. Despite these incidents, the facility's care plan for Resident #2 did not include new interventions to address the increasing behavioral issues. The facility's response to Resident #2's behavior was inadequate, as there were no new interventions added to the care plan to address the resident's escalating behavior. The administrator acknowledged the challenges in managing Resident #2's behavior but did not take effective steps to mitigate the risk to other residents. The lack of timely and appropriate interventions contributed to the ongoing risk of abuse and intimidation faced by Resident #1 and potentially other residents.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the Oklahoma State Department of Health (OSDH) for two residents involved in an incident. The facility's policy mandates that all employees report any reasonable suspicion of abuse, neglect, or misappropriation of property to appropriate authorities, including the OSDH. However, an incident occurred where one resident verbally abused another and subsequently, the second resident threw magazines at the first resident's face. Despite this act of physical aggression, the incident was not reported to the OSDH. The Director of Nursing (DON) and the administrator concluded that the magazines were pushed off the table and did not make contact, thus deciding it was not a reportable incident. Resident #1, who was involved in the incident, had a history of moderately impaired cognition and was unable to answer interview questions at a later date. Resident #2, who was cognitively intact, reported having a contentious relationship with Resident #1, which included being chased and verbally abused. The DON and the corporate nurse consultant believed the incident did not warrant reporting due to the nature of the residents' relationship. However, the facility's failure to report the incident as required by their policy and state regulations constitutes a deficiency in their handling of abuse allegations.
Failure to Notify Physician of Missed Antibiotic Therapy
Penalty
Summary
The facility failed to notify the physician of missed antibiotic therapy for a resident with possible osteomyelitis. The resident, who had diagnoses including right below-knee amputation (BKA), diabetic ulcer, diabetes mellitus, and high cholesterol, was not administered Cipro as prescribed. Specifically, the resident missed two doses of Cipro 500 mg and three doses of Cipro 250 mg over specified periods. Despite the facility's policy requiring physician consultation for significant treatment alterations, the physician was not informed of the missed doses. The deficiency was identified through observation, record review, and interview, confirming that the doctor should have been notified and the dose schedule adjusted accordingly.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure MDS assessments were accurate for four residents. Resident #59, who had diagnoses including a right BKA, diabetic ulcer, diabetes mellitus, and high cholesterol, had discrepancies in the documentation of their diabetic foot ulcer. The MDS did not document the diabetic foot ulcer, despite multiple wound care notes indicating its presence. Similarly, Resident #6, diagnosed with psychotic disorder, anxiety, atherosclerotic heart disease, depressive disorder, and bipolar disorder, had inaccuracies in their MDS assessments regarding the administration of antidepressant and diuretic medications, which were not supported by physician orders in the clinical record. Resident #34, diagnosed with anxiety, had an MDS assessment that incorrectly documented the administration of an antianxiety medication, whereas the prescribed medication, Hydroxyzine, is classified as an antihistamine. Lastly, Resident #61, with diagnoses including senile degeneration of the brain and dementia, had inconsistencies in their MDS assessment regarding their communication abilities. The assessment indicated severe cognitive impairment and that a resident mood interview should not be conducted, yet the MDS coordinator stated the resident understood and was able to make themselves understood. These inaccuracies highlight a failure in ensuring accurate MDS assessments for the residents involved.
Multiple Deficiencies in Care Coordination and Treatment Administration
Penalty
Summary
The facility failed to ensure proper coordination of care with hospice services for a resident diagnosed with senile degeneration of the brain. The care plan did not document how care would be coordinated between the nursing facility and hospice providers. Additionally, there was no documentation in the clinical record or hospice records to indicate that hospice staff had visited the resident or provided the required care, such as bathing, as documented by the facility. The Director of Nursing (DON) confirmed that care coordination with hospice had not been established for this resident. The facility also failed to follow physician orders for obtaining lab tests for a resident with Diabetes Mellitus. Despite a physician's progress note indicating the need to monitor HgBA1C every three to six months, there were no HgBA1C lab results in the resident's clinical records. The DON acknowledged that there were no current lab orders for the resident and confirmed that the physician's progress note should be considered a valid order. Furthermore, the facility did not administer wound care treatments as ordered for two residents with chronic ulcers. One resident's dressing, dated several days prior, had not been changed daily as required. Another resident with a diabetic ulcer had not been referred to a wound care center as ordered by the physician. Additionally, the facility failed to ensure a resident with weight loss was in the dining room for all meals as per physician orders. The resident was observed eating meals in their room, contrary to the care plan and physician's order. The DON confirmed that the resident had not been taken to the dining room for meals as required.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure pressure ulcer treatment was provided as ordered for one of the three sampled residents reviewed for pressure ulcers. Resident #56, who had diagnoses including chronic non-pressure ulcers and deep tissue injury (DTI), had a physician's order to cleanse the right lateral foot with normal saline, pat dry, apply nickel-thick Santyl, Durafiber, and cover with a border foam dressing daily and as needed. However, on observation, the dressing on Resident #56's right foot was dated 04/26/24, and the bed pad under the resident's foot had yellow, tan, and pink-colored drainage, indicating the dressing had not been changed as ordered. The resident confirmed that staff changed the dressing only every few days, contrary to the daily requirement in the physician's order. Further investigation revealed that the wound care nurse was responsible for wound care Monday through Friday, while charge nurses handled it on weekends. When asked, both a CNA and an LPN confirmed that the dressing on Resident #56's right foot was dated 04/26/24, and the LPN observed an open area with necrotic tissue and red peri-wound on the right lateral foot, with no dressing in place. The LPN stated that wound care was supposed to be provided daily and that staff should replace any dressing that came off. However, the observations and interviews indicated that the facility did not adhere to these protocols, leading to inadequate pressure ulcer care for Resident #56.
Narcotic Count and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the accuracy of narcotic counts and the proper documentation of eight-hour verification sheets. Specifically, an individual narcotic count sheet for a resident receiving Oxycodone was found to be incorrect, with a discrepancy between the documented count and the actual number of pills remaining. The resident's Medication Administration Record (MAR) indicated that doses had been administered, but the physical count did not match, raising concerns about whether the medication had been properly administered or documented. The Corporate Nurse Consultant was informed of the discrepancy but could not confirm if the resident had received the medication as prescribed. Additionally, the facility did not consistently complete eight-hour verification sheets at shift changes. Review of the verification sheets for March, April, and May revealed numerous instances where signatures were missing, indicating that shift change counts were not properly documented. The Pharmacy Consultant confirmed that there should not be any blanks on the verification sheets, and the Corporate Nurse Consultant acknowledged that the sheets were not filled out according to policy. This lack of proper documentation and verification could lead to significant issues in medication management and resident care.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control during medication administration, as observed with two Certified Medication Aides (CMAs). CMA #3 was seen preparing medications for a resident and, after a pill fell onto the medication cart, picked it up with their bare hands and placed it into the medication cup before administering it to the resident. When questioned, CMA #3 confirmed the pill had dropped and acknowledged that they had used their fingers to place it in the cup, despite knowing the policy against touching medications with bare hands. Similarly, CMA #1 was observed popping medications out of 14 blister packs directly into their bare hand before placing them into a medicine cup. When asked about the policy for administering medications, CMA #1 initially stated they did not touch the medications with their hands but later denied popping the medications into their hand. The Corporate Nurse Consultant confirmed that staff should not touch medications with their bare hands and should discard any medication that falls on the cart and obtain a new one.
Failure to Offer Advance Directive Information
Penalty
Summary
The facility failed to ensure that information was offered to formulate an advance directive for one of the three sampled residents reviewed for advance directives. Resident #61, who was admitted to the facility and had a physician order indicating full code status, was later admitted to hospice services for senile degeneration of the brain. However, the clinical record did not contain documentation that information had been offered to Resident #61 or their representative to formulate an advance directive. The Director of Nursing (DON) confirmed that this information should have been reviewed when hospice was ordered but admitted that the paperwork was still pending and had not been offered prior to hospice services.
Failure to Maintain Clean Mattress
Penalty
Summary
The facility failed to ensure a mattress was not soiled for one of eight mattresses observed for a homelike environment. During an observation, a resident's bed was found unmade and without linens, revealing a mattress with brown residue and brown rings. A CNA confirmed that the brown ring was dried urine and the brown substance was feces. The CNA stated that mattresses were inspected during linen changes and disinfected twice a week, but the soiled condition of the mattress indicated a lapse in these procedures.
Failure to Complete Annual Comprehensive Assessment
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed every 12 months for one of the sampled residents. Resident #73 was admitted to the facility and had an Admission Assessment completed on 04/24/23. Subsequent Quarterly Assessments were completed on 07/11/23, 10/11/23, 01/09/24, and 03/29/24. However, an Annual or other comprehensive assessment was not completed as required. On 05/23/24, the DON, MDS coordinator, and Consultant RN confirmed that the comprehensive assessment should have been completed on 03/29/24, but a quarterly assessment was done instead.
Failure to Provide Proper Nail Care
Penalty
Summary
The facility failed to ensure proper nail care for a resident with severe cognitive impairment and multiple dependencies on staff for activities of daily living (ADLs). The resident, who had diagnoses including dementia and high blood pressure, was observed with long and overgrown toenails and brown debris under their long fingernails. Despite the facility's policy on fingernail care aimed at reducing infections and maintaining hygiene, the resident's nails were not properly maintained. Staff, including an RN, acknowledged the need for nail trimming but did not take action to address the issue. The deficiency was observed during multiple instances of care provided to the resident, highlighting a lapse in adherence to the facility's hygiene policies.
Failure to Secure Smoking Products for Supervised Resident
Penalty
Summary
The facility failed to ensure that smoking products, specifically a lighter, were kept secure for a resident who required supervision while smoking. The resident had severe cognitive impairment and was diagnosed with paroxysmal atrial fibrillation, anoxic brain damage, and angina. According to the facility's Smoking Policy and Procedure, residents who require supervision to smoke must surrender their cigarettes and lighters to facility staff for safekeeping. However, observations on multiple occasions revealed that the resident had a lighter on their over-the-bed table, contrary to the policy and the resident's care plan, which stated that the resident must keep cigarettes and lighter on the nurse's cart and be accompanied by staff or family while smoking. The Director of Nursing (DON) confirmed that the smoking policy had not been followed and acknowledged that the resident required supervision while smoking. The DON also indicated that the facility attempts to communicate with staff regarding which residents can keep their smoking materials, but this communication was evidently insufficient in this case. The deficiency was identified through observations, record reviews, and interviews, highlighting a lapse in the facility's adherence to its own smoking policy and procedures for residents requiring supervision while smoking.
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Illustrative
What surveyors actually found near you
We read the 230 citations issued within 25 miles in the last 12 months — including the 11 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
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Illustrative
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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) |
|---|---|---|---|---|
| Accel At Crystal Park | 0.8 mi | ★★★★★ | 10 | 1 |
| Meadowlake Estates | 1.6 mi | ★★★★★ | 1 | 0 |
| Emerald Care Center Southwest Llc | 1.9 mi | ★★★★★ | 1 | 0 |
| Capitol Hill Skilled Nursing And Therapy | 2.4 mi | ★★★★★ | 0 | 0 |
| South Pointe Rehabilitation And Care Center | 2.5 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.