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 Callaway Nursing Home during CMS and state inspections, most recent first.
A resident re-admitted after hospital treatment for bacterial pneumonia did not receive multiple new and changed medications as ordered by the hospital physician. The medications were not added to the resident's orders or administered during the stay, as confirmed by the DON, until the resident was transferred back to the hospital for respiratory concerns.
A resident with a history of constipation, cerebral palsy, and intellectual disabilities experienced several days without a bowel movement, followed by symptoms of nausea and vomiting. Despite care plan instructions, staff did not perform a nursing assessment or intervene appropriately, and there was confusion among staff regarding reporting and monitoring bowel movements. The resident's condition deteriorated, resulting in hospital admission for a high-grade small bowel obstruction.
A resident with cognitive impairment and multiple diagnoses was ordered a wrist restraint and referred to an inpatient psych facility. The facility failed to notify the resident's designated representative/POA of these significant changes, instead contacting another family member, which was not in accordance with facility policy.
A resident with cognitive impairment and physical disabilities was repeatedly placed in a wrist restraint due to self-harm and aggressive behaviors, without documented discussion or written consent from the resident or their representative, contrary to facility policy. Family members observed the resident in distress while restrained, and staff reported that restraints were not to be used in the facility.
The facility did not have a registered nurse serving as the full-time DON, as required by policy and regulation. Staff interviews and record review confirmed that after the previous DON resigned, no RN was designated to fulfill this role, despite the facility having 44 residents.
The facility did not provide or document advance directive information for three residents, including those who were cognitively intact and those with severe cognitive impairment, despite their full code status and complex medical histories. The Business Office Manager confirmed that there was no process in place to address or educate residents about advance directives, and the facility lacked a specific policy on this matter.
The facility did not perform required weekly blood pressure checks for a resident with hypertension and failed to follow hold parameters for blood pressure medication for another resident, resulting in medication being administered despite low systolic blood pressure readings. These deficiencies were confirmed by staff review of documentation and medication records.
The facility did not maintain adequate nursing and direct care staffing, with multiple days lacking RN hours and several shifts without 24-hour licensed nurse coverage. Agency staff were used for nearly all CNA, CMA, and licensed nurse roles, and aides were often required to perform housekeeping duties in addition to resident care. Staffing levels varied with census and call-ins, sometimes leaving only one CNA per hall, and there was no consistent core RN coverage.
The facility did not have a Legionella water management program or policy in place, and no Legionella testing had been conducted. The maintenance supervisor had not received training on Legionella, and only an information packet was available, affecting 44 residents.
The facility did not follow its antibiotic stewardship protocols, as antibiotics were prescribed to three residents with severe cognitive impairment for various infections without completing the required assessment forms. The MDS coordinator confirmed that the necessary documentation was missing for all residents, indicating the program was not implemented as outlined in facility policy.
Surveyors observed persistent uncleanliness and disrepair in common areas, including stained floors, trash, and soiled items left for days, as well as a strong urine odor and a door with a missing knob. Housekeeping was provided by agency staff with no weekend coverage, and CNAs reported cleaning duties often conflicted with resident care responsibilities. Facility policy required all staff to maintain cleanliness, but this was not consistently followed.
A resident with multiple medical conditions did not receive scheduled showers as required, instead resorting to cleaning themselves with wet wipes. The resident reported only receiving showers about every two weeks despite being scheduled for twice weekly, and staff were unable to provide documentation of completed showers. The resident expressed dissatisfaction with late evening shower times and had made several complaints without resolution.
The facility did not designate a qualified staff member as the infection preventionist, as required by its own policy and national standards. Review of the staff roster and confirmation from the DON showed that no one was assigned to oversee the infection prevention and control program, despite 44 residents being present.
A facility failed to issue a timely refund of a resident's personal funds within the required 30 days after discharge. The resident was transferred to another LTC facility, but refund checks were issued nearly two months later. The administrator was unaware of the delay's cause, as the business office manager had left the facility.
The facility failed to report abuse allegations involving two residents to the State Agency as required. One resident, with severe cognitive impairment, was involved in an incident where they became aggressive during care, resulting in scratches. Despite internal reporting, no incident report or notification to the State Agency was made. Another resident, with moderate cognitive impairment, reported verbal abuse by a CMA. The administrator's investigation deemed the claim unsubstantiated, leading to no incident report or notification. These actions violated the facility's reporting policy.
The facility failed to investigate and document allegations of abuse involving two residents. One resident, with severe cognitive impairment, was found with scratches after an aggressive incident during care, but the investigation lacked documentation and witness statements. Another resident, with moderate cognitive impairment, reported verbal abuse by a CMA, but the investigation was incomplete, lacking resident interviews and proper documentation.
The facility did not transmit MDS data to CMS within the required 14 days, as assessments from May to July 2024 were delayed. An LPN, who started as the MDS coordinator in July, reported transmission issues that were resolved by October, allowing for a batch submission of 200 assessments.
The facility failed to ensure RN coverage for at least eight consecutive hours daily and did not have a full-time DON. Staff schedules for August, September, and October 2024 showed multiple days without RN or DON coverage. Interviews confirmed inconsistent RN presence, with no RN assuming DON duties. A new DON was expected to start soon.
The facility did not provide EMR access to surveyors during a complaint investigation, despite being informed of the requirement. The administrator indicated that the receiver refused to comply, offering to print documents instead, leading to a deficiency in compliance.
Failure to Administer Hospital-Ordered Medications Upon Readmission
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident who was re-admitted from the hospital after treatment for bacterial pneumonia. Upon re-admission, the resident's hospital discharge medication list included several new and changed medications, such as bronchodilators, diuretics, antipsychotics, cardiac medications, anticonvulsants, supplements, and other treatments. These medications were not added to the resident's physician orders in the facility, and none of them were administered as ordered during the resident's stay following re-admission. Documentation shows that the resident was re-admitted to the facility with specific medication orders from the hospital, but these were not implemented. The Director of Nursing confirmed that the medications listed on the hospital discharge papers were not given to the resident from the time of re-admission until the resident was transferred back to the hospital due to respiratory concerns. The failure to follow physician orders for medication administration was identified through record review and staff interview.
Failure to Assess and Intervene for Bowel Obstruction
Penalty
Summary
A deficiency occurred when the facility failed to assess, monitor, and intervene for a resident who had not had a bowel movement for several days, despite the resident's care plan indicating the need to check bowel sounds and notify a physician if no bowel movement occurred for three days. The resident, who had diagnoses including constipation, cerebral palsy, and intellectual disabilities, was always incontinent of bowel and required staff assistance for activities of daily living. Bowel elimination records showed the resident had no bowel movement for five consecutive days, followed by a single medium-sized bowel movement, and then again no bowel movement for two days. During this period, the resident began experiencing symptoms such as nausea and vomiting, which were documented in progress notes. Despite these symptoms and the absence of bowel movements, there was no documented nursing assessment related to the vomiting or constipation. Staff interviews revealed that CNAs were expected to report lack of bowel movements to nurses, but there was confusion about the process and lack of access to electronic medical records for some staff. The ADON confirmed that there was no policy in place for assessing and monitoring bowel movements at the time, and that intervention should have started at the beginning of the fourth day without a bowel movement. The resident's condition worsened, leading to transfer to the emergency room for self-harm, altered mental status, and low blood pressure. A CT scan at the hospital revealed a high-grade small bowel obstruction, and the resident was admitted for further evaluation. Family members reported that the resident had been complaining of stomach pain and refusing to eat prior to hospitalization, and that these concerns had been communicated to facility staff.
Failure to Notify Resident's Representative of Significant Change and Restraint Use
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition and treatment, specifically regarding the use of a physical restraint and a referral to an inpatient psychiatric facility. According to facility policy, the representative must be immediately informed of significant changes in the resident's physical, mental, or psychosocial status, as well as any significant alterations in treatment. Documentation showed that a nurse practitioner ordered a wrist restraint and a transfer to an inpatient psychiatric facility for a resident with moderately impaired cognition, as indicated by a BIMS score of 09 and diagnoses including cerebral palsy and intellectual disabilities. Although a progress note indicated that a family member was notified of the resident's behaviors, the new restraint order, and the psychiatric referral, the resident's designated representative and POA was not contacted. The responsible party/POA later reported not being informed of these developments. The ADON confirmed that the charge nurse failed to notify the resident's representative/POA and instead contacted another family member, contrary to facility policy.
Failure to Prevent Unauthorized Use of Physical Restraint
Penalty
Summary
A resident with cerebral palsy, intellectual disabilities, and moderately impaired cognition (BIMS score of 09) was physically restrained multiple times over the course of several hours. The facility's policy required that physical restraints not be used unless there was an emergency, and only after thorough discussion with the resident or their representative and obtaining written consent. Documentation showed that the resident engaged in repeated self-harm behaviors, including putting fingers down their throat to induce vomiting, and was subsequently placed in a wrist restraint following a nurse practitioner's order. The restraint was applied, removed, and reapplied several times as the resident continued to display self-harming behaviors and aggression toward staff. There was no documentation indicating that the required discussion with the resident or their representative occurred, nor that written consent was obtained prior to the use of the restraint. Family members observed the resident restrained and reported that the resident appeared distressed and complained of stomach pain. Facility staff, including the MDS coordinator, indicated that restraints were not to be used in the facility and were unaware of any restraints being available. The use of the restraint was not consistent with facility policy, and the resident's representative was not involved in the decision-making process as required.
Failure to Maintain Full-Time Director of Nursing (DON)
Penalty
Summary
The facility failed to have a registered nurse serving as the full-time Director of Nursing (DON), as required by both facility policy and regulatory standards. Record review and staff interviews revealed that the facility did not have an RN acting in the capacity of DON at the time of the survey. The Assistant Director of Nursing (ADON) confirmed during the entrance conference that there was no current DON, and the administrator reported that the previous DON had resigned the previous week, with their last day worked being 04/14/25. The facility's own policy stated that a registered nurse must be designated to serve as the DON on a full-time basis, but this requirement was not met during the period reviewed. At the time, the facility had 44 residents.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to inform and provide written information regarding advance directives to residents or their representatives, as required. For three sampled residents, there was no documentation in either the hard chart or electronic medical record indicating that advance directive information had been provided. These residents included individuals who were both cognitively intact and severely cognitively impaired, with diagnoses such as congestive heart failure, hypertension, renal insufficiency, diabetes mellitus, depression, schizophrenia, anxiety, bipolar disorder, and a history of traumatic brain injury. All three residents were documented as full code status in their physician orders and care plans, but there was no evidence that advance directive options or information had been discussed or offered. During interviews, the Business Office Manager (BOM) confirmed that the facility did not address advance directives with newly admitted residents or their representatives and did not have a process in place to offer information or education about advance directives to current residents. The BOM also stated that while the admission packet included a section on resident rights, it did not contain specific information related to advance directives. Additionally, the facility was unable to provide an advance directive policy when requested.
Failure to Follow Physician Orders for Blood Pressure Monitoring and Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders and medication hold parameters for two residents. For one resident with a history of hypertension, diabetes, mood disorder, dementia, psychosis, and benign intracranial hypertension, there were documented gaps in weekly blood pressure monitoring as ordered by the physician. The resident's care plan required weekly blood pressure checks and documentation, but the facility was unable to provide records of these checks for several months, coinciding with a transition to an electronic medical record system. This lack of documentation was confirmed by the MDS coordinator. For another resident with hypertension and moderate cognitive impairment, the facility did not adhere to the physician's order to hold Carvedilol if the systolic blood pressure was less than 120. The medication administration record showed multiple instances where the medication was given despite systolic blood pressure readings below the specified threshold. Both the ADON and a CMA acknowledged that the medication should have been held according to the order, but it was administered regardless.
Insufficient Nursing and Direct Care Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days with no RN hours and several shifts without 24-hour licensed nursing coverage, according to PBJ Staffing Data Reports from October through December 2024. The Quality of Care Monthly Reports for January, February, and March 2025 further documented numerous shifts across all times of day with insufficient direct care staff for the reported resident census. Interviews revealed that the facility relied almost entirely on agency staff for CNAs, CMAs, and licensed nurses, with no core staff RNs consistently covering specific shifts. The Director of Nursing had resigned in April 2025, and the Assistant Director of Nursing was the only full-time core staff nurse, while the MDS coordinator was shared with another facility. CNA staff reported that, in addition to their care duties, they were often responsible for housekeeping tasks such as emptying trash, cleaning bathrooms, and sweeping floors, especially when housekeeping staff were unavailable or their hours were uncertain. Staffing levels fluctuated based on resident census and staff call-ins, sometimes resulting in only one CNA per hall. The administrator confirmed the lack of consistent RN coverage and the heavy reliance on agency staff, with RN shift coverage varying week to week and no core staff RNs assigned to regular shifts.
Failure to Develop Legionella Water Management Program
Penalty
Summary
The facility failed to develop and implement a water management program for Legionella, as required for infection prevention and control. Record review showed that no Legionella testing had been conducted according to the maintenance air and water temperature log. When requested, the administrator provided only an information packet on Legionella, which did not include a formal policy. The maintenance supervisor, who was recently hired, reported not having a detailed diagram of the facility, no water management program in place, and no training on Legionella, aside from receiving an information packet. The administrator confirmed that there was no Legionella water management policy available at the time of the survey. A total of 44 residents were reported to be residing in the facility during the time of the deficiency.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, specifically for three residents who were prescribed antibiotics. According to the facility's undated policy, protocols should be in place to optimize infection treatment and ensure antibiotics are prescribed appropriately, with residents assessed using standardized tools and criteria. However, record review showed that for three residents with severe cognitive impairment and diagnoses such as dementia and Alzheimer's disease, antibiotics were prescribed for conditions including urinary tract infection, COVID-19, and other infections. Despite these prescriptions, there was no documentation that the required Loeb minimum criteria forms were completed to justify the initiation of antibiotic therapy. During an interview, the MDS coordinator confirmed that the facility was supposed to use the Loeb minimum criteria forms when starting antibiotic therapy, but no such forms were found for any residents, including the three sampled. The coordinator was unable to account for the missing forms or confirm if they had ever been used, indicating a lack of adherence to the facility's own antibiotic stewardship protocols.
Failure to Maintain Clean and Homelike Environment in Common Areas
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its 44 residents, as evidenced by multiple observations of uncleanliness and disrepair in common areas. During several tours, surveyors noted dirt and brown stains on floors in the main lobby, hallways, dining room, and common areas. A common area at the end of the women's hall was repeatedly observed to have trash, including a fast-food sack, candy wrappers, a soiled brief/diaper, and a crushed soda can on the floor. The area also had a strong urine odor, and a door was found with a plastic bag stuffed into a hole where a doorknob should have been. These conditions persisted over several days, with trash and soiled items remaining in place despite the presence of housekeeping staff in the building. Interviews with staff revealed that all housekeeping personnel were contracted through an agency, with no housekeeping coverage on weekends. CNAs, including agency staff, reported that they were responsible for cleaning tasks such as emptying trash and cleaning bathrooms, but often had to prioritize resident care over cleaning. Housekeeping staff acknowledged the poor condition of the floors and indicated that they had not yet been trained to use a floor stripper, which they believed would help address the stains. Facility policy required all staff to ensure common areas were clean and neat, but observations and staff interviews indicated this was not consistently achieved.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled and requested, resulting in a deficiency related to activities of daily living assistance. Observation showed the resident cleaning themselves with a wet wipe, and the resident reported feeling unclean due to not receiving regular showers. The resident stated they were supposed to receive showers twice a week but only received them approximately every two weeks, despite making multiple complaints to staff. The resident also indicated a preference not to be scheduled for showers late in the evening when they were tired, and reported never being given a reason for the delay. Documentation review revealed a previous refusal of a shower by the resident, but staff interviews indicated the resident did not refuse showers for all staff members. The ADON was unaware of the missed showers, and the MDS coordinator could not provide documentation of completed showers due to missing shower sheets after the previous DON left. The facility's policy emphasized the importance of showers for cleanliness, comfort, and skin observation, but this was not consistently provided to the resident.
Failure to Designate Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the infection preventionist responsible for the infection prevention and control program. Review of the facility's undated policy indicated the requirement for an infection preventionist to oversee the infection prevention and control program for all residents, staff, volunteers, visitors, and contracted individuals. However, an undated staff roster did not list an infection preventionist, and during an interview, the DON confirmed that the facility was currently without an infection preventionist. At the time of the survey, there were 44 residents residing in the facility.
Delayed Refund of Resident's Personal Funds
Penalty
Summary
The facility failed to ensure a timely refund of a resident's personal funds within 30 days of discharge, as required by their Resident Funds policy. The policy mandates that upon discharge, eviction, or death, the facility must convey the resident's funds and a final accounting of those funds within 30 days, in accordance with State law. A physician's order and progress note documented that a resident was discharged to another long-term care facility. However, the refund checks for the resident's funds were issued nearly two months later, with one check dated March 25 and another dated March 26, despite the discharge occurring on January 29. The administrator was unaware of the reason for the delay, as the business office manager responsible for the refund no longer worked at the facility.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency (OSDH) and other officials as required for two residents. The first incident involved a resident with Huntington's disease, depression, vascular dementia, mood disorder, and anxiety, who was severely impaired with cognition. An incident occurred where the resident became aggressive during care, resulting in scratches on their chest and neck. Despite the incident being reported internally, there was no documentation of an incident report or notification to the State Agency. Interviews with staff and review of camera footage did not substantiate the abuse claim, but the lack of formal reporting and documentation was a deficiency. The second incident involved a resident with schizophrenia, peripheral vascular disease, Type 2 diabetes, bipolar disease, depression, and pain, who was moderately impaired with cognition. The resident reported that a CMA cursed at them and almost hit them with a door. The administrator investigated the complaint, including reviewing camera footage and interviewing the CMA and other employees. The claim was deemed unsubstantiated, and no incident report was completed, nor was the allegation reported to the State Agency. This failure to report was a deficiency in the facility's handling of abuse allegations. In both cases, the facility's policy required immediate reporting of abuse allegations to the State Agency, but this was not followed. The administrator's determination that the allegations were unsubstantiated led to a failure to complete incident reports and notify the required authorities. This lack of adherence to reporting protocols resulted in deficiencies in the facility's compliance with regulatory requirements.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of abuse involving two residents. For the first resident, who had diagnoses including Huntington's disease and severe cognitive impairment, an incident occurred where the resident became aggressive during care, resulting in scratches on their chest and neck. The Assistant Director of Nursing (ADON) assessed the resident and interviewed them, but the resident denied being hurt. Despite interviewing other residents, there was no documentation of these interviews, and a statement from a key witness, CNA #3, was not obtained. The incident was reported to the administrator, but the investigation lacked thorough documentation and follow-up. For the second resident, who had diagnoses including schizophrenia and moderate cognitive impairment, a grievance was filed alleging that a Certified Medication Aide (CMA) cursed at the resident and almost hit them with a door. The administrator suspended the CMA and conducted an investigation, which included reviewing camera footage and employee statements. However, there was no documentation of interviews with other residents, and the claim was deemed unsubstantiated. The administrator admitted to not completing an incident report or documenting all findings, indicating a failure to conduct a comprehensive investigation.
Failure to Timely Transmit MDS Data
Penalty
Summary
The facility failed to electronically transmit completed Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) system within the required 14 days of completion. The facility's policy mandates compliance with quality reporting requirements, including the timely submission of MDS data to the CMS database. However, a review of MDS data revealed that assessments were not submitted from May 1, 2024, to July 8, 2024. During a phone interview, an LPN who began working as the MDS coordinator in July 2024 reported that the facility had been experiencing difficulties in transmitting MDS data, which had only recently been resolved. The LPN managed to transmit a batch of approximately 200 MDS assessments on October 8, 2024.
Failure to Maintain Required RN and DON Coverage
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, and did not have a director of nursing (DON) on a full-time basis. The review of staff time cards and schedules for August, September, and October 2024 revealed multiple days without RN or DON coverage. Specifically, there was no RN or DON coverage on several days in August, and in September, the DON worked only a few days with no other RN coverage documented. In October, the last day the DON worked was early in the month, with numerous days lacking RN coverage thereafter. Interviews conducted on November 14, 2024, with the assistant director of nursing (ADON) and the administrator confirmed the lack of consistent RN and DON coverage. The ADON reported that RN coverage was available on most weekends but was unsure if any RN covered DON responsibilities. The administrator confirmed that RN #1 worked most weekends and occasionally at night but did not assume any DON duties. The administrator also mentioned that the previous DON had last worked in early October and that a new DON was expected to start the following week. No staffing waivers were reported to be in place.
Facility Denies EMR Access to Surveyors
Penalty
Summary
The facility failed to grant access to the Electronic Medical Records (EMR) for the survey team during a complaint investigation. Upon entering the facility, surveyors were informed by the administrator that the facility utilized an EMR system, which staff members were observed using. The surveyors requested access to the EMR for record review, which is a standard requirement during such investigations. However, the administrator reported that the receiver of the facility had instructed that access to the EMR would not be provided to surveyors. Despite being informed of the necessity to grant access to avoid impeding the survey process, the receiver refused to comply, offering instead to print any requested documentation. This refusal to provide EMR access constituted a deficiency in the facility's compliance with regulatory requirements.
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 29 citations issued within 25 miles in the last 12 months — 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 Sulphur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Artesian Home | 1.6 mi | ★★★★★ | 9 | 0 |
| Burford Manor | 7.4 mi | ★★★★★ | 0 | 0 |
| Pauls Valley Care Center | 18.3 mi | ★★★★★ | 13 | 0 |
| Washita Valley Living Center | 19.1 mi | ★★★★★ | 0 | 0 |
| Ballard Nursing Center | 24.4 mi | ★★★★★ | 7 | 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.