Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Cedarcrest Care Center during CMS and state inspections, most recent first.
The facility did not complete required initial competency and skills checklists for multiple newly hired CNAs. Review of personnel records showed that several CNAs lacked documented competency assessments corresponding to their hire dates, despite the DON identifying multiple licensed staff who should have had initial competencies completed. The business office manager confirmed that no skills checklists or competency documents were available for the requested files, and the DON acknowledged that initial skills competencies should have been done but could not explain why they were not completed.
Staff did not recognize or report a resident-to-resident altercation as abuse within the required two-hour window, instead initially reporting it as an injury. The DON later confirmed the incident should have been reported as abuse according to facility policy.
A resident with Alzheimer's and dementia was found with a swollen and discolored lip with bite marks, but the facility failed to conduct a thorough investigation. The DON did not document discussions with day shift staff, did not speak with night shift staff, and did not perform a skin assessment, contrary to the facility's abuse prevention policy.
The facility failed to prevent abuse, with incidents involving resident-to-resident aggression and staff-to-resident abuse. A resident with Alzheimer's exhibited aggressive behaviors, including choking another resident. Another resident with a memory deficit was harmed during an altercation. Additionally, a resident with dementia was abused by a CNA, resulting in physical injuries. Staff noted insufficient interventions, particularly during evening shifts, to prevent these incidents.
A facility failed to prevent resident-to-resident abuse and staff abuse. A resident with Alzheimer's dementia exhibited aggressive behaviors, including choking another resident with a memory deficit. Despite staff attempts to redirect and engage residents, interventions were insufficient. Additionally, a CNA was observed hitting a resident with a towel after being spat on, following antagonistic behavior. The DON acknowledged the incidents and the lack of effective interventions.
The facility failed to update care plans for two residents involved in abuse incidents. One resident with Alzheimer's dementia exhibited aggression, including choking another resident who wandered into their room. Staff noted a lack of evening activities to mitigate such behaviors. Another incident involved a resident with dementia being abused by a CNA, who hit the resident with a towel after being spat on. The facility's intervention of having two staff present during showers was ineffective, as multiple staff were already present during the incident.
A facility failed to report an abuse allegation within the required timeframe. A CNA allegedly abused a resident with dementia by hitting them with a wet, soapy towel and making derogatory comments. The incident was reported to administration a day late, delaying notification to authorities. Additionally, the report to the Nurse Aide Registry was not completed in a timely manner.
The facility failed to report abuse allegations within the required timeframe, involving both resident-to-resident and staff-to-resident incidents. A resident was found choking another, and a CNA allegedly abused a resident with a towel. Delays in reporting to authorities and ineffective interventions were noted, with the DON acknowledging the inadequacy of current measures.
Failure to Complete Initial Competency Assessments for Newly Hired CNAs
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had appropriate initial competency assessments completed upon hire, as required to maximize each resident’s well-being. Record review showed that three certified nurse aides (CNA #5, CNA #10, and CNA #11) did not have completed competency/skills checklists corresponding to their hire dates of 04/11/25, 12/02/25, and 09/25/25, respectively. The Director of Nursing (DON) identified a total of 14 licensed staff members who should have had initial competencies completed. On 03/04/26 at 9:28 a.m., the business office manager confirmed there were no skills checklists or competencies available for the requested employee files. Later that day, at 11:03 a.m., the DON stated that the facility should be conducting initial skills competencies on staff and did not know why these were not completed.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to recognize and report an incident of potential abuse within the required two-hour timeframe for two residents involved in a resident-to-resident altercation. According to facility policy, all allegations of abuse, neglect, mistreatment, or misappropriation of resident property must be reported immediately, but no later than two hours after the allegation is made. In this case, an unwitnessed incident occurred in which one resident was found on the ground in another resident's room after staff heard a noise. The resident was assessed and found to have no injuries, while the other resident was sent for psychiatric evaluation. The incident was initially reported as an injury rather than abuse, and the Director of Nursing later acknowledged that it should have been recognized and reported as abuse within the required timeframe.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident diagnosed with Alzheimer's disease, dementia, anxiety, and delusional disorders. The resident was found with a discolored and swollen top lip with bite marks underneath, which was not present the day before. The incident was reported to the Oklahoma State Department of Health, and the resident's family was notified. However, the investigation process was incomplete as the Director of Nursing (DON) did not document discussions with the day shift staff, did not speak with the night shift staff, and did not conduct a skin assessment during the investigation. The facility's undated Abuse Prevention Policy and Procedure required an immediate investigation into any allegation of abuse, neglect, or misappropriation of resident property. Despite this policy, the DON, who was responsible for the investigation, did not follow through with a comprehensive investigation. The lack of documentation and communication with all relevant staff members, as well as the absence of a skin assessment, contributed to the failure to determine the cause of the resident's injury. This deficiency highlights a gap in the facility's adherence to its own policies regarding the investigation of potential abuse or neglect incidents.
Failure to Prevent Abuse in LTC Facility
Penalty
Summary
The facility failed to provide an environment free of abuse, as evidenced by multiple incidents involving resident-to-resident aggression and staff-to-resident abuse. Resident #1, diagnosed with Alzheimer's dementia, exhibited aggressive behaviors towards other residents, including pushing, throwing water, and choking another resident. These incidents were documented over several months, with staff noting that Resident #1's aggression typically increased in the evening. Despite attempts to separate Resident #1 from others and engage them in activities, the interventions were insufficient to prevent further incidents. Resident #2, who had a memory deficit following a stroke, was a victim of abuse when Resident #1 choked them after they wandered into Resident #1's room. The incident resulted in physical harm to Resident #2, including scratches and a purple complexion. Staff interviews revealed that Resident #1 had a history of aggression, and there were concerns about the lack of organized activities during the evening shift to mitigate such behaviors. The facility's Director of Nursing acknowledged the failure of current interventions to prevent the incident. Additionally, Resident #3, diagnosed with dementia and behavioral disturbances, was subjected to abuse by CNA #1, who repeatedly hit them with a wet, soapy towel after the resident allegedly spat on the CNA. Witnesses reported that CNA #1 antagonized Resident #3, leading to the altercation. The incident resulted in physical injuries to Resident #3, including bleeding and irritation. The facility's response to this incident was to ensure two staff members assist Resident #3 during showers to prevent further abuse.
Failure to Prevent Resident and Staff Abuse
Penalty
Summary
The facility failed to provide an environment free from resident-to-resident abuse and did not ensure that staff accused of abuse were removed from resident access until a thorough investigation was conducted. Resident #1, diagnosed with Alzheimer's dementia, exhibited aggressive behaviors towards other residents, including pushing, throwing water, and choking another resident, Resident #2, who had a memory deficit following a stroke. These incidents occurred over several months, with staff noting Resident #1's aggression typically increased in the evening. Despite attempts to redirect and engage residents in activities, the facility's interventions were insufficient to prevent Resident #1 from attacking Resident #2 when they found them in their roommate's bed. Additionally, the facility failed to protect Resident #3 from staff abuse. An incident report documented that CNA #1 was observed hitting Resident #3 with a wet, soapy towel after the resident allegedly spat on them. Further investigation revealed that CNA #1 had antagonized Resident #3 by flicking their nose and making derogatory comments, leading to the resident's agitation and subsequent spitting. Despite another CNA's attempts to intervene, CNA #1 continued the abusive behavior until another staff member entered the room. The facility's Director of Nursing (DON) acknowledged the incidents and the failure of current interventions to prevent resident-to-resident abuse. The DON also noted the lack of organized activities during the evening shift, which may have contributed to the incidents. The report highlights the facility's inability to effectively manage resident behaviors and ensure a safe environment for all residents.
Failure to Update Care Plans and Prevent Abuse
Penalty
Summary
The facility failed to update care plans for two residents involved in incidents of abuse. One resident with Alzheimer's dementia exhibited aggressive behavior, including choking another resident who had wandered into their room and laid in their roommate's bed. Staff interviews revealed that the aggressive resident had a history of such behavior, particularly in the evenings, and that there were no organized activities scheduled for the evening shift to mitigate these behaviors. Despite attempts to separate the resident from others and engage them in activities during the day, the interventions were insufficient to prevent the incident. Another incident involved a resident with dementia and behavioral disturbances who was physically abused by a CNA. The CNA was observed hitting the resident with a wet, soapy towel after the resident allegedly spat on them. Witnesses reported that the CNA had antagonized the resident, leading to the spitting incident, and continued to abuse the resident despite requests to stop. The resident sustained injuries, including bleeding from the nose, cheek, and above an eye. The facility's intervention to have two staff members present during showers was deemed inappropriate, as multiple staff were already present during the incident. The facility's Director of Nursing (DON) acknowledged the root causes of the incidents, including the failure to prevent resident wandering and the inappropriate response to resident behavior by staff. The DON admitted that the current interventions were inadequate in preventing these incidents of resident-to-resident and staff-to-resident abuse. The facility did not have effective strategies in place to address the behaviors and prevent further occurrences.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy by not reporting an allegation of abuse within the required two-hour timeframe to the Oklahoma State Department of Health. An incident involving a certified nurse aide (CNA) allegedly abusing a resident with dementia and behavioral disturbances was reported late. The incident occurred when a CNA was observed hitting the resident with a wet, soapy towel and making derogatory comments, which agitated the resident. This incident was not reported to the administration until the following day, delaying the notification to the relevant authorities. Additionally, the facility did not report the incident to the Nurse Aide Registry in a timely manner. The Director of Nursing (DON) attempted to fax the allegation to the Nurse Aide Registry from home, but the fax did not complete successfully. It was only resent from the facility two days later. This delay in reporting to the Nurse Aide Registry further highlights the facility's failure to adhere to its abuse policy and ensure timely communication with the appropriate agencies.
Failure to Timely Report and Address Abuse Allegations
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Oklahoma State Department of Health. An incident involving resident-to-resident abuse occurred when one resident was found choking another resident, resulting in physical harm. The initial incident report was not sent until the following day, indicating a delay in reporting. Additionally, the facility did not take adequate corrective action to prevent further risk of abuse for the residents involved. Another incident involved a certified nurse aide allegedly abusing a resident by hitting them with a wet, soapy towel and making derogatory comments. This incident was not reported to the administration until the day after it occurred, and the alleged perpetrator continued to work until the allegation was confirmed. The facility also failed to report this incident to the Nurse Aide Registry in a timely manner, as the initial attempt to fax the report was unsuccessful. The Director of Nursing (DON) acknowledged that the interventions in place were insufficient to prevent the incidents of abuse. The DON admitted that the facility's intervention of having two staff members present during resident showers was not effective, as the abuse occurred despite the presence of multiple staff members. The facility's inability to implement effective interventions and timely reporting contributed to the deficiencies identified in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Broken Arrow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broken Arrow Nursing Home, Inc | 1.2 mi | ★★★★★ | 0 | 0 |
| Village Health Care Center | 1.5 mi | ★★★★★ | 10 | 1 |
| Aspen Health And Rehab | 1.8 mi | ★★★★★ | 2 | 0 |
| Franciscan Villa | 2.8 mi | ★★★★★ | 2 | 0 |
| Senior Suites Healthcare | 3.5 mi | ★★★★★ | 15 | 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.