Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Colonial Terrace Care Center during CMS and state inspections, most recent first.
A physician failed to respond to a pharmacy consult about a resident’s Seroquel use for dementia-related symptoms. The resident had severe cognitive impairment and was receiving an antipsychotic that the consult noted is not approved for dementia-related psychosis. An LPN stated the medication had been used for vascular dementia since admission, and the DON said the physician should have responded to the consult.
The facility failed to store refrigerated medications at the proper temperature and failed to secure controlled substances in locked storage. A medication room refrigerator contained tuberculin purified derivative at 50 degrees Fahrenheit with no temperature log documented, and an unlocked drawer in the DON’s office contained multiple controlled medications, including hydrocodone/acetaminophen, tramadol, Ativan, morphine, and ABH.
A resident with dementia and depression experienced changes in medication orders, including an increase in Zoloft and a new order for Namenda, without their representative being notified. Additionally, a Fleets enema was administered for constipation without notification. The resident's representative expressed a desire to be informed of such changes, and facility staff confirmed the lack of documentation for notification.
Two residents in the facility received incorrect medication doses due to errors in administration. One resident with acute kidney failure and diabetes was under-dosed with insulin because the medication cart contained outdated supplies. Another resident with atrial fibrillation received a lower dose of Sotalol than prescribed due to a mix-up in the medication cart. The errors were linked to poor communication among nursing staff and failure to follow facility policy.
Two residents received incorrect medication dosages due to errors in administration by an RN. One resident was under-dosed with insulin due to using a pen with the wrong concentration, while another received a lower dose of Sotalol than prescribed. These incidents highlight a failure to adhere to facility policy and standards of care.
The facility failed to maintain the ice machine in a sanitary condition, affecting 38 residents who received nourishment from it. During a survey, substances were found on the machine's deflector panel and coil cover, despite a policy requiring weekly cleaning. The maintenance supervisor acknowledged the need for more frequent cleaning.
A facility failed to maintain infection control for a resident with an indwelling urinary catheter. The resident, who had neuromuscular dysfunction of the bladder and a history of UTIs, was observed multiple times with catheter tubing touching the floor while in a wheelchair. Staff acknowledged that catheter tubing should not touch the floor, indicating a lapse in infection control practices.
A resident with neuropathy did not receive their prescribed diclofenac sodium 1% for pain management on multiple occasions, as documented in the Treatment Administration History. The resident reported not receiving the medication as ordered, and staff confirmed the lack of documentation and administration was an oversight.
The facility failed to promote resident dignity by having staff stand over two residents while assisting them to eat, despite protocols requiring staff to sit next to residents during meal assistance.
Physician Did Not Respond to Pharmacy Consult on Antipsychotic Use
Penalty
Summary
The facility failed to ensure a physician responded to a pharmacy consult report regarding the use of an antipsychotic medication for a resident diagnosed with dementia. Resident #7 had a quarterly assessment showing a BIMS score of three, indicating severe cognitive impairment, and had been receiving Seroquel. A pharmacy consultation report dated 02/18/26 stated that Seroquel is not approved for dementia-related psychosis and requested verification or update of the diagnosis and documentation of the rationale for antipsychotic use. The physician signed the consultation report but did not provide a rationale or a new order for the resident’s Seroquel. During interview, an LPN stated the resident was prescribed Seroquel for vascular dementia since admission, and the DON stated the physician should have responded to the pharmacy consultation and usually did, but no policy was found on physician response to a pharmacy consult.
Improper Storage of Refrigerated Medications and Controlled Substances
Penalty
Summary
The facility failed to ensure that medications requiring refrigeration were stored at the appropriate temperature and that controlled substances were stored in securely locked containers. During observation of the medication room, a small refrigerator contained a cardboard box of medication and did not have a temperature log for the date reviewed. The thermometer inside the refrigerator read 50 degrees Fahrenheit, and the medication observed in the box was tuberculin purified derivative, a sterile diluted protein solution used intradermally to test for Mycobacterium tuberculosis infection. An LPN stated the refrigerator temperature was 50 degrees Fahrenheit and needed to be 46 degrees Fahrenheit or colder, and a CMA stated there was no documented temperature reading on the refrigerator logbook for that date. During observation of the DON's office while the DON was present, the office was unlocked and the DON's desk had an unlocked drawer containing controlled medications, including 42 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg, 14 tablets of Tramadol 50 mg, 8 syringes of Ativan 1 mg, 19 syringes of Morphine 0.25 milliliters, and 30 syringes of ABH. The DON stated that anyone could have entered the office and removed the unsecured narcotic medications from the desk drawer. The DON also stated discontinued medications were destroyed every other month with the pharmacist.
Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to notify the representative of a resident with dementia, recurrent depressive disorders, and constipation about changes in medication orders. The resident's Zoloft dosage was increased from 25 mg to 50 mg daily for depression, and Namenda was ordered for dementia. These changes were documented in the Medication Administration Record and a Progress Note, but there was no evidence that the resident's representative was informed of these changes. Additionally, the resident was administered a Fleets enema for constipation, as documented in a Progress Note, but again, there was no indication that the representative was notified of this new order. The resident was noted to be severely impaired in cognition for daily decision-making, emphasizing the importance of notifying the representative. Interviews with the resident's representative and facility staff confirmed the lack of notification, with the representative expressing a desire to be informed of such changes.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to administer the correct doses of medications as ordered by physicians for two residents. Resident #19, who had acute kidney failure and diabetes mellitus with diabetic neuropathy, was prescribed five units of lispro insulin from a 200 unit per milliliter strength insulin pen before each meal. However, RN #1 administered insulin using a pen with a strength of 100 units per milliliter, resulting in the resident being under-dosed. This error occurred because the insulin pens in the medication cart had not been updated since the order change in January. Resident #93, diagnosed with paroxysmal atrial fibrillation, was prescribed one 120 mg tablet of Sotalol every morning. Instead, RN #1 administered an 80 mg tablet, as the medication cart contained both the correct and incorrect doses. The error was attributed to a lack of communication among the nursing staff, leading to discontinued medications remaining in the cart. The Regional Nurse confirmed that RN #1 did not adhere to facility policy or standards of care by failing to verify the medications against the physician's orders.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by two separate incidents involving incorrect medication administration. The first incident involved Resident #19, who was prescribed Humalog KwikPen Insulin at a concentration of 200 units per milliliter, with a dosage of 5 units to be administered subcutaneously. However, on June 18, 2024, RN #1 administered insulin using a pen with a concentration of 100 units per milliliter, resulting in an under-dose for the resident. This error was confirmed upon review of the resident's medication orders and the insulin pen used. The second incident involved Resident #93, who was prescribed a 120 mg tablet of Sotalol to be administered via gastric tube. On June 19, 2024, RN #1 administered an 80 mg tablet instead, again resulting in an under-dose. This discrepancy was identified during a review of the resident's medication orders and the medication container. The Regional Nurse confirmed that RN #1 did not adhere to facility policy or standards of care by failing to verify the medications against the physician's orders before administration.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the ice machine in a sanitary condition, as observed during a survey. The ice machine, which provided nourishment to 38 residents, was found to have a black/brown substance on the deflector panel and an orange/yellow substance on the coil cover, both of which were easily wiped off with a paper towel. The facility's policy required the ice machine to be cleaned weekly, and records indicated it had been cleaned on three occasions in June 2024. However, during an observation with the dietary manager, it was noted that the maintenance supervisor, who was responsible for cleaning the machine, acknowledged that the machine appeared to need more frequent cleaning due to the buildup.
Infection Control Lapse with Indwelling Catheter
Penalty
Summary
The facility failed to maintain infection control for a resident with an indwelling urinary catheter. Resident #16, who had diagnoses including neuromuscular dysfunction of the bladder, retention of urine, and a history of urinary tract infections, was observed multiple times with their catheter tubing touching the floor. The resident required maximal assistance for transfers and was dependent on staff, as noted in their quarterly assessment. Observations on three separate occasions revealed the catheter tubing dragging on the floor while the resident was in their wheelchair. Both a CNA and an RN acknowledged that catheter tubing should not touch the floor, indicating a lapse in infection control practices.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as per the physician's order for a resident diagnosed with neuropathy. The resident was prescribed diclofenac sodium 1% to be applied topically to both feet twice daily. However, the Treatment Administration History revealed that the medication was not documented as administered on several occasions, specifically on April 8th, April 11th, May 30th, and June 10th, 2024. There was no documentation in the progress notes for these months explaining the missing administration of the medication. The resident expressed that they did not receive the medication on some days and desired it to be administered as ordered for pain management. Corporate nurse #1 confirmed the lack of documentation and had no explanation for the oversight. RN #1 acknowledged that the resident would often remind the nurses about the medication, indicating that the failure to document and administer the medication was an oversight without a known reason.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote resident dignity by having staff stand over residents while assisting them to eat. This was observed in two residents. One resident, diagnosed with achondroplasia and severe cognitive impairment, required partial/moderate assistance with eating. A CNA was observed standing over this resident while assisting them with breakfast. The CNA acknowledged that the protocol required them to sit next to the resident but admitted they did not follow this protocol. Another resident, diagnosed with CHF, SOB, diabetes, and seizures, required substantial/maximal assistance with eating. The DON was observed standing over this resident while assisting them with breakfast. The DON also acknowledged that the protocol required them to sit next to the resident but admitted they did not follow this protocol.
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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 Pryor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shady Rest Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Parkhill North Nursing Home | 7.1 mi | ★★★★★ | 13 | 0 |
| Meadowbrook Nursing Center | 9.4 mi | ★★★★★ | 20 | 1 |
| Lane Nursing & Ventilator Care | 16.9 mi | ★★★★★ | 0 | 0 |
| Claremore Skilled Nursing And Therapy | 18 mi | ★★★★★ | 5 | 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.