Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Coweta Care & Rehab Center during CMS and state inspections, most recent first.
Two residents received inaccurate MDS assessments: one was incorrectly coded as having taken an anticoagulant instead of an antiplatelet, and another's discharge status was inaccurately documented as a facility death rather than a hospital transfer following a pulmonary embolism.
A resident with a newly identified diagnosis of bipolar disorder did not receive a required referral for a PASRR Level II evaluation after a significant change in status. The initial screening showed no mental health disorder, but the diagnosis was later added to the medical record, and no documentation of a referral was found.
A medication cart was left unlocked and unattended in a hallway with keys hanging from the lock, while residents were present in the area. An LPN also left multi-dose medication packages unsecured on the cart while administering medication to a resident, contrary to facility policy requiring medications to be locked or attended by authorized personnel.
A resident requiring a pureed diet was served meatloaf that was not properly blended, resulting in a chunky and grainy texture that required chewing. The dietary staff and dietician failed to ensure the puree met the required consistency before it was placed on the serving line.
A facility failed to adhere to infection control protocols during incontinent care for a resident with acute respiratory failure. Two CNAs did not wear gowns or change gloves and perform hand hygiene after cleansing the perineal area, contrary to facility policies. The lapse was confirmed by the CNAs, an LPN, and the DON.
The facility failed to ensure that three shower rooms containing hazardous chemicals were locked and secure. Observations revealed that the rooms had various unsecured chemicals, and staff interviews indicated that the locks had been malfunctioning for weeks without corrective action. Additionally, a room near the nurses' station containing hand sanitizer was also found to be unlocked.
The facility failed to conduct required AIMS assessments for three residents on antipsychotic medications, leading to a deficiency. Staff interviews revealed inconsistencies and misunderstandings about the responsibility and frequency of these assessments.
The facility failed to ensure that evening snacks were offered to residents as per their policy. Observations and interviews revealed that residents had to go to the nurses' station to request snacks, and staff were not consistently offering snacks to residents in their rooms. Seven residents reported not being offered an evening snack, and staff interviews confirmed the inconsistency in offering snacks.
The facility failed to follow infection control protocols during medication administration. An LPN did not properly sanitize a glucometer before checking a resident's blood sugar and did not sanitize their hands before drawing and administering insulin. An RN confirmed the protocol was to let the device air dry for two minutes before and after use.
The facility failed to ensure mail delivery to residents on Saturdays. Four residents reported not receiving mail on Saturdays. The activity director and administrator confirmed that mail was only delivered from Monday through Friday, affecting the 73 residents in the facility.
A resident with type two diabetes was transferred to a hospital without proper documentation or notification to the physician or resident representative. The transfer occurred during a transition to an electronic medical record system and was not documented by the nurse on duty over the weekend.
The facility failed to ensure accurate assessments for a resident with hypertension. The quarterly assessment documented anticoagulant use, but the Medication Administration Record did not show any anticoagulant medication administered. The MDS coordinator incorrectly coded the use of an anticoagulant because the resident was given Plavix, an antiplatelet medication.
The facility failed to ensure that a dependent resident received baths according to their care plan. Despite the care plan indicating the need for assistance with bathing, only eight out of 14 scheduled bathing opportunities were completed, with no refusals documented. Observations and staff interviews revealed inconsistencies in the bathing schedule and documentation practices, and the administrator was unaware of the issue.
A facility failed to implement range of motion (ROM) interventions for a resident with limited ROM and contractures. Despite a physician order for restorative therapy and a care plan indicating ROM exercises three times per week, the resident did not consistently receive these services. The restorative aide was unaware of any interventions, and the MDS coordinator confirmed the care plan was incorrect.
The facility failed to ensure the proper positioning of a urinary drainage bag for a resident with a nephrostomy tube, as specified in the care plan. Multiple observations showed the bag placed on the bed by the resident's feet, contrary to instructions. Staff miscommunication and lack of documentation of the resident's preference contributed to this deficiency.
A resident with adult failure to thrive and dementia experienced a significant weight loss of 20 pounds over 30 days. The registered dietitian recommended weekly weights, but this recommendation was missed by the facility's administration. The issue of potentially inaccurate weights was acknowledged by the administrator, but the recommendation was not implemented until identified during the survey.
The facility failed to ensure medications were securely stored for two of the four medication carts observed. On multiple occasions, medication carts on the 100/200 and 500/600 halls were found unlocked and unattended. Staff members acknowledged that medication carts should be secured when unattended, but failed to consistently follow this protocol.
The facility failed to serve food at a palatable temperature, as reported by three residents and observed by surveyors. The administrator was unaware of any complaints but committed to investigating the issue.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two of twenty-eight sampled residents. For one resident, the MDS assessment incorrectly indicated the use of an anticoagulant during the look-back period, while the resident was actually prescribed and administered an antiplatelet medication, Clopidogrel Bisulfate, for blood clot prevention. The MDS coordinator acknowledged the error, stating that the assessment was miscoded despite efforts to ensure accuracy during completion. For another resident, discrepancies were found in the discharge assessment. The resident, who was cognitively intact and had diagnoses including anemia, urinary tract infection, and arthritis, experienced a medical emergency and was sent to the hospital, where a pulmonary embolism was diagnosed. The resident died at the hospital, but the MDS discharge assessment inaccurately documented the resident as having died in the facility. The MDS coordinator confirmed after reviewing the clinical record that the discharge should have reflected a transfer to the hospital rather than a death in the facility.
Failure to Refer for PASRR Level II After New Mental Health Diagnosis
Penalty
Summary
The facility failed to make a required referral to the Oklahoma Health Care Authority (OHCA) for a Pre-Admission Screening and Resident Review (PASRR) Level II after a resident was newly diagnosed with a serious mental health disorder. Initially, the resident's PASRR Level I form indicated no mental health disorder, and no Level II referral was deemed necessary. However, a diagnosis of bipolar disorder was later added to the resident's medical record. Despite this significant change in the resident's status, as documented in a subsequent assessment showing intact cognition, there was no evidence that a PASRR Level II referral was made. The MDS coordinator confirmed the absence of documentation for such a referral following the new diagnosis.
Failure to Secure Medication Cart and Medications
Penalty
Summary
A deficiency was identified when drugs and biologicals were not stored in locked compartments as required. During an observation, a medication cart was found unlocked in the Southwest corridor with a set of keys hanging from the lock and no staff present. At the time, three residents were independently moving in the hallway, and the unattended cart was accessible. Additionally, during a medication pass, an LPN removed medications from multi-dose pharmacy-prepared packages and left them on the cart while entering a resident's room, leaving the cart and medications unattended. Upon returning, a resident in a wheelchair was observed sitting by the medication cart. Facility policy states that only authorized personnel should have unsupervised access to medications and that medication carts must be locked or attended at all times. The LPN admitted to forgetting to lock the cart and leaving the keys in the lock due to being in a hurry, and was unaware that the multi-dose medication packages were left unsecured. The DON confirmed that medication carts should always be locked when unattended and that as-needed narcotic medications are stored in the medication carts on the halls.
Pureed Food Served with Improper Consistency
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the appropriate consistency for residents requiring this diet. During meal preparation, a cook processed meatloaf with beef base and hot water, then asked the dietician to check the puree. The surveyor tasted the puree and found it to be chunky with bits that required chewing, indicating it was not smooth as required for a pureed diet. The dietician did not taste the puree but told the cook it was acceptable to serve. The puree was then poured into a container and placed on the steam table for serving. The surveyor later stopped the serving of the puree after observing its texture. The dietary manager subsequently confirmed the puree was grainy and not smooth, and the dietician acknowledged it needed further blending.
Infection Control Lapse During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during incontinent care for a resident. Specifically, two CNAs were observed providing care without wearing gowns, which is required under the facility's Enhanced Barrier Precautions policy for high-contact activities like changing briefs. Additionally, the CNAs did not change gloves or perform hand hygiene after cleansing the perineal area, as stipulated in the facility's Incontinent Care policy. The resident involved had diagnoses including gastrostomy status and acute respiratory failure. Interviews with the CNAs and the LPN confirmed that the expected procedures were not followed, and the Director of Nursing acknowledged the lapse in protocol adherence.
Failure to Secure Shower Rooms Containing Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that three of three shower rooms containing chemicals were locked and secure. During observations, it was noted that the shower rooms on hall #2, hall #3, and hall #4 had various unsecured chemicals, including unlabeled spray bottles, hard surface cleaners, body washes, and razors without safety caps. These chemicals were labeled to be kept out of reach of children, yet the rooms were found unlocked. Staff interviews revealed that the locks on these doors had been malfunctioning for weeks, and the issue had been reported to housekeeping and maintenance, but no corrective action had been taken. Additionally, a room near the nurses' station on halls #5 and #6, which contained hand sanitizer, was also found to be unlocked. The Director of Nursing (DON) identified that 73 residents resided at the facility, including a resident known to be a wanderer. The maintenance supervisor acknowledged that the keypads to the showers and supply storage had been unlocked by staff and needed to be reset. Despite the maintenance supervisor locking the hall #2 shower room and the PPE room near the nurses' station, the failure to secure these areas initially posed a significant risk to the residents, particularly those who might wander into these unsecured areas and access hazardous chemicals.
Failure to Conduct Required AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents on antipsychotic medications were assessed for tardive dyskinesia as required. Specifically, three residents with diagnoses including paranoid schizophrenia, schizophrenia, and Wernicke's encephalopathy were not given the necessary AIMS assessments quarterly. For Resident #3, the last AIMS assessment was completed in October 2023, despite a physician order for Seroquel in March 2024. Similarly, Resident #34 had their last AIMS assessment in September 2023, even though they were prescribed Zyprexa in March 2024. Resident #32, who was on multiple psychoactive medications, missed AIMS assessments in September 2023, December 2023, and March 2024. Additionally, psychoactive evaluations were not completed for Resident #32 as per the facility's policy. Interviews with staff revealed inconsistencies and misunderstandings regarding the responsibility and frequency of AIMS assessments. RN #1 and the ADON provided conflicting information about who was responsible for completing these assessments and how often they should be done. RN #1 admitted that monitoring for symptoms of tardive dyskinesia was not conducted for Residents #3 and #32, and only behavior and side effect monitoring were performed. This lack of proper assessment and monitoring led to the deficiency identified in the report.
Failure to Offer Evening Snacks to Residents
Penalty
Summary
The facility failed to ensure that evening snacks were offered to residents as per their policy. The Meals and Snacks policy, dated 03/31/21, stated that nursing staff were responsible for distributing snacks to residents in the evening. However, observations and interviews revealed that residents had to go to the nurses' station to request snacks, and staff were not consistently offering snacks to residents in their rooms. Specifically, seven residents reported not being offered an evening snack, and some had to request snacks from the nurses' station. Staff interviews confirmed that snacks were not routinely offered to all residents, and there was a lack of clarity on how bed-bound residents would receive snacks if they did not request them. One CNA admitted to not offering a snack to a resident they had just assisted to bed, despite claiming to have offered snacks to all residents on their hall. An LPN and an RN also confirmed that residents could request snacks at the nurses' station, but there was no consistent practice of offering snacks to all residents in the evening. The deficiency was observed on multiple occasions, with residents in wheelchairs seen requesting snacks at the nurses' station and several residents stating they had not been offered an evening snack. The facility's failure to adhere to its own policy resulted in residents not receiving evening snacks unless they specifically requested them, highlighting a gap in the implementation of the policy by the nursing staff. This inconsistency in offering snacks could potentially affect the nutritional intake and satisfaction of the residents, particularly those who are bed-bound or less mobile.
Infection Control Protocols Not Followed During Medication Administration
Penalty
Summary
The facility failed to ensure infection control protocols were followed during medication administration. Specifically, an LPN did not properly sanitize a glucometer before checking a resident's blood sugar. The LPN used a Sani-wipe but did not wait the full two minutes and wipe it again as required to ensure blood-borne pathogens were eradicated. Additionally, the LPN did not sanitize their hands before drawing insulin into a syringe and administering it to the resident. An RN confirmed that the infection control protocol for glucometers was to follow the manufacturer guidelines, which include letting the device air dry for two minutes before and after use with purple top Sani-wipes.
Failure to Ensure Mail Delivery on Saturdays
Penalty
Summary
The facility failed to ensure mail delivery to residents on Saturdays. During a resident group meeting, four residents reported that they did not receive mail on Saturdays. The activity director confirmed that mail was obtained from the post office and delivered to residents from Monday through Friday, but was unsure if anyone delivered mail on Saturdays. The administrator also confirmed that mail delivery occurred only from Monday through Friday, with no one assigned to deliver mail on Saturdays. This affected the 73 residents residing in the facility.
Failure to Document Resident Transfer
Penalty
Summary
The facility failed to ensure the discharge of Resident #78 was documented in the medical record. Resident #78, who had a diagnosis of type two diabetes, was transferred to a hospital without proper documentation or notification to the physician or resident representative. A nurse's note dated 03/04/24 mentioned a phone call to an unidentified hospital about the resident's condition, but no reason for the transfer was recorded in the medical record. LPN #1 confirmed the absence of documentation regarding the transfer. The administrator later stated that the transfer occurred during a transition to an electronic medical record system and was not documented by the nurse on duty over the weekend.
Inaccurate Resident Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure accurate assessments for a resident with hypertension. The quarterly assessment documented that the resident had received an anticoagulant medication during the seven-day look-back period. However, the Medication Administration Record for the same period did not show that the resident had received any anticoagulant medication. The MDS coordinator reviewed the clinical record and incorrectly coded the use of an anticoagulant because the resident was administered Plavix, an antiplatelet medication, not an anticoagulant.
Failure to Provide Scheduled Baths for Dependent Resident
Penalty
Summary
The facility failed to ensure that dependent residents were offered or received baths according to their preferences. Specifically, Resident #15, who had diagnoses including colostomy status and acute kidney failure, required partial to moderate assistance for bathing and was moderately impaired in cognition for daily decision-making. Despite the care plan indicating that Resident #15 should receive assistance with bathing and be offered a bed bath when a shower was not tolerated, the electronic clinical record showed that only eight out of 14 scheduled bathing opportunities were completed, with no refusals documented. Observations and interviews revealed inconsistencies in the bathing schedule and documentation practices among the staff. On one occasion, Resident #15 was observed to have oily hair and stated they received approximately one shower per week, contrary to the care plan. Interviews with CMA #1 and CNA #2 provided conflicting information about the bathing schedule, with one stating the resident should receive three showers a week and the other stating the resident received showers on different days. The administrator was unaware of any issues regarding residents not receiving baths as scheduled, indicating a lack of oversight and communication within the facility.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to ensure that range of motion (ROM) interventions were implemented for a resident with limited range of motion. Resident #47, who had diagnoses including impingement syndrome of both shoulders, had a physician order for restorative therapy dated 09/23/22. However, the resident was removed from the restorative nursing program as documented in a form dated September 2023. Despite the care plan indicating that the resident was on the restorative program three times per week for contractures, observations and interviews revealed inconsistencies in the provision of ROM exercises and the use of splints or devices for the resident's contracted fingers. The resident reported that ROM exercises were not provided consistently, and the restorative aide was unaware of any interventions for the resident's limited range of motion. Further review of the restorative therapy binder did not show that Resident #47 was receiving restorative nursing services, even though the order for restorative therapy was still active. The MDS coordinator confirmed that the care plan was incorrect and that the resident was not on the restorative program at the time of the survey. The resident had been on and off the restorative program and had refused therapy at times. However, the resident had requested restorative therapy earlier on the day of the survey. No additional information was provided by the end of the survey to clarify the interventions in place for the resident's contractures.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure the proper positioning of a urinary drainage bag for a resident with a nephrostomy tube. The resident's care plan specified that the drainage bag should be maintained below the level of the kidney at all times. However, multiple observations revealed that the drainage bag was placed on the bed by the resident's feet, contrary to the care plan instructions. This improper positioning was confirmed by both a CNA and an LPN, who stated they placed the bag on the bed to prevent it from getting smashed between the bed and the wall. The LPN also incorrectly believed that the bag could be placed at the same level as the kidney, which contradicts the care plan requirements. Further interviews revealed that the resident did not prefer the drainage bag to be placed on the bed, despite staff claims to the contrary. The resident's preference regarding the placement of the drainage bag was not documented. The RN acknowledged the need to place the drainage bag below the kidney but was unaware of the resident's actual preference. This lack of adherence to the care plan and miscommunication among staff led to the deficiency in providing appropriate catheter care for the resident.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to ensure weights were monitored as recommended by the registered dietitian for a resident diagnosed with adult failure to thrive and dementia. The resident's electronic health record documented a significant weight loss of 20 pounds over 30 days. The registered dietitian recommended weekly weights to address the weight loss, but this recommendation was missed by the facility's administration. The dietitian brought the issue of potentially inaccurate weights to the attention of the administrator, who acknowledged the problem and indicated that the facility was correcting it. However, the recommendation for weekly weights was not implemented until the deficiency was identified during the survey.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure medications were securely stored for two of the four medication carts observed. On multiple occasions, medication carts on the 100/200 and 500/600 halls were found unlocked and unattended. Specifically, on 04/30/24, the 500/600 hall medication cart was left unlocked and unattended near the nurse's station, and later, an LPN had their back to the unlocked cart. On 05/01/24, an LPN left the 100/200 hall medication cart unlocked and unattended while performing a fingerstick blood sugar check for a resident. Staff members, including an LPN and a CMA, acknowledged that medication carts should be secured when unattended, but failed to consistently follow this protocol.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure food was served at a palatable temperature for one noon meal observed for palatability. Resident #69 reported that their food was served cold to their room and that cold salads were placed on plates with hot food, causing the vegetables to wilt. During a resident group meeting, two other residents also stated that their meals were often served cold in their rooms. An observation of the last tray on the back hall cart revealed that the cornbread, broccoli with cheese, and potatoes were not served at a palatable temperature. The administrator stated they had not received any complaints about cold food but would investigate the concern.
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 153 citations issued within 25 miles in the last 12 months — including the 3 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 Coweta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haskell Care Center | 8.7 mi | ★★★★★ | 0 | 0 |
| Village Health Care Center | 10.5 mi | ★★★★★ | 10 | 1 |
| Cedarcrest Care Center | 10.6 mi | ★★★★★ | 1 | 0 |
| Aspen Health And Rehab | 11.6 mi | ★★★★★ | 2 | 0 |
| Broken Arrow Nursing Home, Inc | 11.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Coweta Care & Rehab Center.
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 July 2026) and official state health department websites.