Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Park Manor during CMS and state inspections, most recent first.
Failure to Establish and Document a Grievance Process: The facility did not have a grievance policy, grievance official, or documentation of grievance outcomes. A resident council meeting showed two cognitively intact residents did not know what a grievance was or how to file one. The SSD, DON, BOM, and Administrator all acknowledged grievances were handled informally, could not be filed anonymously, and were not documented with the resident’s response.
Staff were not consistently fit-tested for N95 respirators on an annual basis, with multiple nurses and the IP reporting the last testing was more than a year ago or not recently recalled, while the DON said annual testing had been the prior practice. In a separate issue, a resident with severe cognitive impairment and an indwelling urinary catheter was observed with the catheter bag attached to a trash can liner and lying on the floor, with the drainage valve touching the floor; staff acknowledged the bag should not have been on the floor.
A resident was admitted with recurrent unspecified major depressive disorder, but the Level I PASARR and related state assessment did not reflect the diagnosis of serious mental illness. The DON later stated the diagnosis was present on admission and should have been included, and state PASARR reps confirmed it was required to be indicated and had not been communicated to their office.
Failure to post and retain daily nurse staffing data. The facility’s lobby whiteboard showed staffing assignments but did not include the resident census on multiple observed days, and the ADM stated there was no policy for the required daily postings. The facility also did not keep copies of the daily staffing postings because the whiteboard was changed each day.
Incomplete Medicare Beneficiary Notices: The facility failed to fully complete SNF ABN and NOMNC forms for three residents. The forms were missing resident names, and several did not identify the services involved or the services ending coverage. The BOM, ADON, DON, and Administrator all acknowledged the notices were not complete and did not provide the details needed for informed decision making.
The facility failed to ensure infection control in linen transport, catheter care, and Legionella prevention. A laundry aide did not cover clean linens during transport, and an LPN reused a washcloth during catheter care, violating infection control policies. Additionally, the facility lacked a water management program to prevent Legionella growth, with the maintenance supervisor unaware of the requirements.
The facility failed to ensure accurate assessments for two residents receiving hospice services. One resident with renal cancer had assessments that did not reflect their terminal condition, despite hospice certification forms indicating a prognosis of six months or less. Another resident with Alzheimer's and dementia had inconsistent assessments regarding hospice status, with sections of the assessments contradicting each other. The MDS coordinator confirmed the inaccuracies.
A facility failed to include the use of assist bars/side rails in a comprehensive care plan for a resident with muscle weakness and severe cognitive impairment. Despite recommendations for assist bars to promote independence, the care plan did not reflect their use. The DON acknowledged the oversight, noting that the care plan only encouraged prescribed assistive devices, and the assist bars/side rails were not prescribed.
A facility failed to assess entrapment risks and obtain informed consent for a resident using assist bars/side rails. The resident, with muscle weakness and cognitive impairment, was observed with the rails up, but the facility did not document a physician's order or informed consent. Staff interviews revealed that assessments did not address entrapment risks or alternatives, and the care plan did not include the use of the rails.
The facility failed to monitor the temperature of a medication storage room and did not secure medications, as observed with unlocked treatment carts. Additionally, glucose test strips were found opened and undated, contrary to facility policy. The DON confirmed the lack of temperature logs and acknowledged the protocol to lock carts and date opened items.
A facility failed to conduct regular inspections of bed rails for a resident with muscle weakness and cognitive impairment, despite policy requirements. Observations showed the resident with assist bars in the up position, but maintenance staff did not routinely monitor or document inspections for safety. The administrator confirmed the lack of documentation for regular inspections.
Failure to Establish and Document a Grievance Process
Penalty
Summary
The facility failed to develop a grievance policy, appoint a grievance official, and maintain documentation of the results of all grievances. During interviews, the Business Office Manager, Administrator, Social Services Director (SSD), and Director of Nursing (DON) each acknowledged that the facility did not have a grievance policy, did not have a grievance official, and did not document the resident’s concern, follow-up, resolution, or the resident’s response to the resolution. The Administrator also acknowledged there was no way for a resident to file a grievance anonymously, and that concerns were handled through a charge nurse, Resident Council, or the SSD. Resident #21, admitted on 06/22/2025, and Resident #36, admitted on 04/19/2019, both had BIMS scores of 15 on their MDS assessments, indicating intact cognition. During the Resident Council meeting, both residents stated they did not know what a grievance was or how to file one. The SSD stated that if a resident had a concern, she would notify the appropriate department and inform residents of the resolution during Resident Council, but there was no documentation of how grievances were resolved or the resident’s response. The DON stated he expected concerns to be resolved within a reasonable amount of time and documented, but he was unaware of any grievance log or form.
N95 Fit Testing Not Current and Catheter Bag Left on Floor
Penalty
Summary
The facility failed to ensure all staff were fit-tested for N95 respirator masks prior to initial use and at least annually thereafter. A facility policy titled, Staff Fit Testing for N95 Respirator Policy, stated OSHA requires fit testing on an at-hire and annual basis, and OSHA guidance cited in the report stated employees using a tight-fitting facepiece respirator must be fit tested prior to initial use and at least annually thereafter. During interviews, an LPN stated she could not recall the last time she was fit tested and believed it had not been done in the last year or two, another LPN stated he was last tested around 2022 or 2023, and the IP stated it had been a little over a year since the last fit testing was completed. The DON stated fit testing used to be done annually but said they did not have much knowledge of the policy or guidance, and the Administrator stated she expected the guidelines to be followed. The facility also failed to ensure a urinary catheter bag was not directly on the floor for Resident #64. The resident was admitted on 07/30/2021 and had diagnoses including senile degeneration of the brain, urinary tract infection, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms. A quarterly MDS assessment showed a BIMS score of 4, indicating severe cognitive impairment, and also indicated the resident had an indwelling urinary catheter. The care plan included a focus area for the urinary catheter and urinary retention, and the active order summary showed an order for an indwelling urinary catheter started on 06/22/2023. Observations on 07/13/2026 and 07/14/2026 showed the resident seated in a recliner with the catheter bag attached to a trash can liner and lying on the floor next to the chair, with the drainage valve in contact with the floor. During a concurrent observation, a CNA stated the catheter bag should not be on the floor and would normally be hung on something, while an LPN stated the bag was likely on the floor because the hook had broken and said placing it on the floor would be a potential for infection. Other staff stated the bag should not be on the floor, and the IP and DON both stated the drainage bag should not have been on the floor or hung on a trash can.
PASARR Screening Did Not Reflect Major Depressive Disorder
Penalty
Summary
The facility failed to ensure that the Level I PASARR accurately reflected a serious mental illness diagnosis for one resident. The resident was admitted with a secondary diagnosis of recurrent unspecified major depressive disorder, and the admission MDS showed a BIMS score of 14, indicating intact cognition. However, the Oklahoma Health Care Authority Nursing Facility Level of Care Assessment completed for the admission indicated that the resident did not have a diagnosis of serious mental illness, and the diagnosis of recurrent unspecified major depressive disorder was not reflected on the Level I PASARR screening. Facility policy stated that the initial PASARR screening is completed prior to admission to identify individuals who have or may have a mental disorder or intellectual disability and who may require Level II evaluation. During interviews, the DON stated the PASARR had been completed by the previous DON and acknowledged that the major depressive disorder was present on admission and should have been included on the Level I PASARR. State PASARR representatives stated the diagnosis was required to be indicated on the PASARR and had not been communicated to their office. The DON and Administrator stated they expected PASARRs to be completed prior to admission or the day of admission and to accurately include all diagnoses and medications.
Failure to Post and Retain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure daily nurse staffing postings included the resident census on 3 of 3 days that the postings were observed, and it failed to maintain the posted daily nurse staffing data for 18 of 18 months. Observations on 07/13/2026, 07/14/2026, and 07/15/2026 each showed a whiteboard in the front lobby displaying daily staffing assignments but not the resident census. During an interview on 07/15/2026, the Administrator stated the facility did not have a policy for the required daily staff postings, that the whiteboard next to the front nurses' station listed the date, staff on duty, and unit assignments, and that the facility did not retain copies of the daily staff postings because the whiteboard was changed daily.
Incomplete Medicare Beneficiary Notices
Penalty
Summary
The facility failed to ensure beneficiary notices were completed with the resident’s name and the services provided for informed decision making for 3 of 3 sampled residents reviewed for beneficiary notices. The deficiency involved Skilled Nursing Facility Advance Beneficiary Notices (SNF ABNs) and Notices of Medicare Non-Coverage (NOMNCs) that were used to notify residents about Medicare coverage and potential liability for services not covered. For one resident, the SNF ABN indicated the resident may have to pay out of pocket beginning on the episode start date, and the resident selected Option 1, but the form did not document the types of care that might not be covered. The resident name field was blank, and the signature was not fully legible. The resident’s NOMNC also had blank Patient Name and Patient Number fields, and the section for the services for which coverage was ending was left blank. For a second resident, the SNF ABN similarly indicated the resident may have to pay out of pocket and the resident selected Option 1, but the form did not document the services involved and the resident name field was blank. The resident’s NOMNC had blank Patient Name and Patient Number fields, and the section identifying the services ending coverage was blank. For the third resident, the SNF ABN identified physical therapy and daily skilled nursing care as services that might not be covered, but the resident name field was blank. The resident’s NOMNC also had blank Patient Name and Patient Number fields, and the section for the services ending coverage was left blank. During interviews, the BOM stated he was responsible for the SNF ABN forms and acknowledged the missing resident names and missing service details were oversights. The ADON stated the NOMNC forms should have included the resident’s name and that the forms were not complete. The DON and Administrator also reviewed the forms and stated they were not complete and should have included the resident’s name and details of the services provided.
Infection Control Deficiencies in Linen Transport, Catheter Care, and Legionella Prevention
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in three key areas. Firstly, a laundry aide was observed delivering clean linens without covering them, which is against the facility's protocol. The aide admitted to not knowing the requirement to cover linens, and the administrator confirmed that linens should be covered during transport. Secondly, an LPN was observed providing catheter care to a resident with urinary retention using improper technique. The LPN reused the same washcloth to clean the genital area, which contradicts the facility's catheter care policy that mandates using a clean washcloth for each cleansing stroke. The LPN acknowledged that reusing the cloth did not adhere to clean technique and infection control standards. Additionally, the facility did not have an effective plan to prevent and monitor Legionella growth in its water systems. The Legionella Surveillance policy outlines the need for a water management program, including routine maintenance and temperature controls, but the facility failed to provide evidence of such a program. The maintenance supervisor was unaware of the water management requirements until the day of the survey, indicating a lack of implementation and oversight in this critical area.
Inaccurate Hospice Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents receiving hospice services. Resident #67, diagnosed with malignant neoplasm of the right kidney, was ordered hospice services due to renal cancer. Despite hospice certification forms indicating a prognosis of six months or less, quarterly and annual assessments repeatedly failed to reflect the resident's condition or chronic disease that could result in a life expectancy of less than six months. The interim MDS coordinator was unable to explain why the assessments did not accurately reflect the resident's condition. Resident #42, diagnosed with Alzheimer's disease and dementia, had discrepancies in their assessments regarding hospice status. Both the annual and quarterly assessments showed inconsistencies, with section J indicating the resident was not on hospice while section O indicated they were. The MDS coordinator confirmed that the resident was indeed on hospice, highlighting inaccuracies in the assessments.
Failure to Include Assist Bars/Side Rails in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident included the use of assist bars/side rails. The resident, who had a diagnosis of muscle weakness and was severely impaired in cognition for daily decision making, was observed multiple times with bilateral assist bars/side rails in the up position. An Assist Bar Evaluation form recommended the use of an assist bar to promote independence, but the care plan, revised on 03/24/25, did not include the use of assist bars/side rails. The Director of Nursing (DON) acknowledged that the care plan indicated to encourage the use of prescribed assistive devices, but the assist bars/side rails were not prescribed, and a care plan for their use had not been completed.
Failure to Assess Entrapment Risks and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to ensure proper assessments for entrapment risks and obtain informed consent for the use of assist bars/side rails for a resident. The resident, who had a diagnosis of muscle weakness and was severely impaired in cognition for daily decision-making, was observed multiple times with bilateral assist bars/side rails in the up position. The facility's Bed Safety policy required consent and a thorough assessment, including consultation with a physician, to determine the necessity of assist bars/side rails. However, the Assist Bar Evaluation form completed for the resident did not assess the risk of entrapment, and there was no documentation of informed consent or a physician's order for the use of the assist bars/side rails. Interviews with facility staff, including the DON, ADON, and RN, revealed that the assessments conducted did not specifically address the risk of entrapment or explore alternatives to the use of assist bars/side rails. The DON acknowledged that the care plan did not include the use of assist bars/side rails as they were not prescribed, and there was no care plan specifically addressing their use. The ADON confirmed that informed consent was not obtained, despite the family's request for the assist bars/side rails to aid in the resident's bed mobility.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to monitor the temperature of one of its medication storage rooms, as there was no documentation of the temperature being recorded. During an observation, the CMA supervisor was unaware that monitoring the medication room temperature was required. The Director of Nursing (DON) later confirmed that there was no log for the temperature of the medication room, indicating a lack of adherence to the facility's policy, which mandates maintaining a temperature log in the storage area to record temperatures at least once a day. Additionally, the facility did not ensure that medications were secured, as two of the six medication/treatment carts observed were left unlocked and unattended. RN #1 was observed leaving the North Hall treatment cart unlocked multiple times, despite the facility's protocol requiring carts to be locked when unattended. Furthermore, glucose test strips on two of the six medication/treatment carts were found to be opened and not dated, contrary to the facility's expectation that items should be dated when opened. The DON acknowledged that staff should discard any item not dated when opened, as there would be no way to determine when it was opened.
Failure to Conduct Regular Inspections of Bed Rails
Penalty
Summary
The facility failed to ensure regular inspections of beds and bed rails to identify potential entrapment risks for a resident who utilized assist bars/side rails. Observations over several days showed the resident in bed with bilateral assist bars/side rails in the up position. The facility's Bed Safety policy, dated December 2007, required maintenance staff to inspect all beds and related equipment as part of a regular bed safety program. However, the maintenance supervisor and a maintenance worker confirmed that they did not routinely monitor assist bars/side rails or beds for safety, and there was no documentation of regular inspections. The resident involved had a diagnosis of muscle weakness and was assessed as severely impaired in cognition for daily decision-making. An Assist Bar Evaluation form recommended the use of an assist bar to promote independence. Despite this, the facility did not have a documented process for regular inspections of the beds or assist bars/side rails, and the administrator confirmed the absence of such documentation. The maintenance staff only addressed issues as reported by other staff, and there was no routine check or documentation to ensure the safety of the assist bars/side rails.
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 59 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Okemah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Okemah Care Center | 2.1 mi | ★★★★★ | 7 | 0 |
| Rainbow Terrace Care Center | 12.6 mi | ★★★★★ | 0 | 0 |
| Fountain View Manor, Inc | 19.7 mi | ★★★★★ | 7 | 0 |
| Heartway At Henryetta Health And Rehab | 20.1 mi | ★★★★★ | 0 | 0 |
| Elmwood Manor Nursing Home | 20.5 mi | ★★★★★ | 6 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Colonial Park Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.