Above 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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Hills Care And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents did not have all of their care needs addressed in their care plans. One resident with a contracted hand and total dependence on staff lacked documented interventions for the contracture, despite occasional use of hand rolls by staff. Another resident with an indwelling urinary catheter did not have the catheter use included in their care plan, even though it was documented in their assessment. The MDS coordinator confirmed these omissions.
The facility did not consistently provide required ROM services or contracture interventions for residents with physical impairments. Two residents did not receive restorative or ROM services as ordered or requested, and another resident with a contracted hand had no formal interventions documented in the care plan, despite occasional use of hand rolls by an LPN. The DON and MDS coordinator confirmed these deficiencies in care and documentation.
An LPN provided catheter care to a resident with an indwelling urinary catheter without wearing a gown, in violation of the facility's infection control policy. Additionally, clean laundry was delivered to residents using an uncovered cart, contrary to facility procedures. Both staff members involved acknowledged that proper protocols were not followed.
The facility did not ensure that three residents, including individuals with diabetes, stroke, and heart failure, were properly offered or had documentation of pneumococcal immunization in their records. The DON confirmed the absence of required documentation in the electronic clinical record.
A resident who was totally dependent on staff and had intact cognition was found to have an unwitnessed left shoulder subluxation after their family reported pain. The injury was not reported to the State Department of Health as required, despite facility policy mandating immediate notification of injuries of unknown origin. The DON confirmed the incident was not reported externally, although an internal investigation was conducted.
A resident who was totally dependent on staff and had intact cognition experienced a left shoulder injury, later diagnosed as a partial dislocation, after their family reported pain. Although the facility's policy required a thorough investigation of potential abuse or neglect, the DON confirmed that interviews with staff, the physician, and other residents were not documented or conducted.
A resident who depended on staff for ADL care was found with long, unkempt toenails and reported discomfort due to lack of nail care after being taken off hospice. Despite facility policy and documentation indicating the need for toenail trimming, staff did not provide the required care, citing uncertainty about the resident's diabetic status and responsibility for nail care.
A medication/treatment cart was found unlocked and unattended in a hallway, with the responsible LPN later admitting they forgot to lock it. The DON confirmed that all medication/treatment carts are required to be locked when unattended and that monitoring for compliance is ongoing.
A resident with a history of stroke was not offered the COVID-19 vaccine, and there was no documentation in the clinical record to show the vaccine was offered or received. The DON stated the resident was likely absent during the facility's COVID-19 vaccination clinic, resulting in the missed opportunity.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two of twenty sampled residents. For one resident with kidney failure and dementia, who was observed to have a contracted right hand and was totally dependent on staff for care, the care plan did not include any interventions for the hand contracture. Staff reported that hand rolls were sometimes used, but there were no formal interventions documented or consistently implemented. The resident's assessment indicated intact cognition and a range of motion impairment, yet the care plan lacked specific measures to address this issue. For another resident with obstructive and reflux uropathy and retention of urine, who had an indwelling urinary catheter and moderate cognitive impairment, the care plan did not include the use of the catheter. The resident's significant change assessment documented the presence of the catheter, but this was not reflected in the care plan. The MDS coordinator confirmed that the care plan should have included interventions related to the urinary catheter, but this was not done.
Failure to Provide Required Range of Motion and Contracture Interventions
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services and contracture interventions for multiple residents as required by their care plans and clinical assessments. For one resident with hemiplegia and moderate cognitive impairment, restorative services were ordered to be provided two to three times a week, but documentation showed services were only delivered on two occasions during the month, and the resident reported receiving restorative care only once in the past week. The Director of Nursing (DON) confirmed that restorative services had not been performed as indicated. Another resident, also with moderate cognitive impairment and physical impairments, was not assessed for the restorative program despite a family request, and there was no documentation that ROM exercises were provided, even though staff had been instructed to perform them during ADL care. Additionally, a resident with a contracted right hand and total dependence on staff for care had no formal interventions documented in the care plan or electronic health record for the contracture. Although an LPN reported occasionally using hand rolls, there were no consistent or formalized interventions in place, and the MDS coordinator acknowledged that such interventions should have been included in the care plan. These findings demonstrate a lack of adherence to facility policies and physician orders regarding the provision of ROM and contracture management services for residents with identified needs.
Failure to Follow Infection Control Practices During Catheter Care and Laundry Delivery
Penalty
Summary
A deficiency was identified when an LPN provided catheter care to a resident with an indwelling urinary catheter without wearing a gown, contrary to the facility's Enhanced Barrier Precautions policy. The policy requires the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices, regardless of MDRO colonization status. The resident involved had diagnoses including obstructive and reflux uropathy and retention of urine, and was assessed as moderately impaired in cognition. Both the LPN and the DON confirmed that a gown should have been worn during this care activity. Another deficiency was observed when laundry personnel delivered clean personal laundry to residents using an uncovered cart. The laundry cart cover was unavailable because it was being washed, but the staff proceeded to deliver laundry to several rooms without it. The laundry personnel acknowledged that laundry should be covered during delivery, and the laundry supervisor confirmed this expectation.
Failure to Document and Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that residents were offered the pneumococcal immunization as required by policy. For three of five sampled residents reviewed for immunizations, documentation was missing or incomplete in the electronic clinical record. One resident with diabetes had no record of being offered the pneumococcal vaccine. Another resident with a history of stroke was noted as up to date on the vaccine in an assessment, but there was no documentation of when the immunization was given or offered. A third resident with heart failure and moderate cognitive impairment was documented as having declined the vaccine, but there was no record of when education or the offer was provided. The Director of Nursing confirmed that the required documentation was not present for these residents.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin to the Oklahoma State Department of Health as required by policy. A resident with kidney failure and dementia, who was totally dependent on staff for care and had intact cognition, was found to have a left shoulder subluxation after their family reported shoulder pain to nursing staff. The injury was unwitnessed, and the resident was unable to explain how it occurred. Nursing notes documented the assessment, x-ray, and subsequent transfer to the emergency room for evaluation. Despite the facility's policy requiring immediate reporting of injuries of unknown source to the State Survey Agency, the incident was not reported. The Director of Nursing confirmed that an internal investigation was conducted, but the required external notification was not made. The deficiency was identified during a review of records and staff interviews, which confirmed the lack of timely reporting to the appropriate authorities.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with kidney failure and dementia, who was totally dependent on staff for care but had intact cognition. The resident's family reported shoulder pain, and subsequent assessment revealed swelling and warmth in the left shoulder, leading to an x-ray that confirmed a partial dislocation. The resident was later sent to the emergency room for further evaluation. Despite the facility's policy requiring immediate and thorough investigation of potential abuse or neglect, the Director of Nursing acknowledged that while an internal investigation was conducted, there was no documentation of interviews with staff or the physician, nor were other residents interviewed regarding their treatment. Additionally, an LPN on duty at the time of the incident was unaware of the cause of the injury or whether an investigation had been completed.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required substantial assistance with activities of daily living (ADLs) was observed to have long and unkempt toenails while lying in bed. The resident, who had intact cognition as indicated by a BIMS score of 14, reported that since being taken off hospice, no one had trimmed their toenails, resulting in discomfort. Facility records, including a CNA Bathing Review form, had previously noted the need for toenail trimming. Interviews with CNAs revealed uncertainty about whether the resident was diabetic, which affected whether they would trim the toenails or refer the task to a nurse. The facility's policy required nail care to be provided to residents, with nurses responsible for ensuring appropriate care, but this was not carried out for the resident in question.
Unattended and Unlocked Medication Cart Observed
Penalty
Summary
A medication/treatment cart on the 500 hall was observed to be unlocked and unattended across from the restrooms. The cart was one of 15 medication/treatment carts in the facility. The administrator locked the cart upon noticing it was unattended and unlocked, and stated they needed to determine who was responsible for the cart. An LPN later acknowledged that they should have locked the cart but had forgotten. The DON confirmed that medication/treatment carts are required to remain locked when unattended and stated that monitoring for compliance is ongoing.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccination as required by facility policy. Record review showed that one resident, who had a diagnosis of stroke and was not up to date with the COVID-19 vaccine, did not have documentation in the electronic clinical record indicating when the vaccine was offered or received. The Director of Nursing (DON) confirmed that the resident was likely out of the facility during the COVID-19 vaccination clinic and was therefore missed in the vaccination offering process.
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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) |
|---|---|---|---|---|
| Senior Suites Healthcare | 1.2 mi | ★★★★★ | 15 | 0 |
| Ignite Medical Resort Tulsa, Llc | 1.6 mi | ★★★★★ | 1 | 0 |
| Aspen Health And Rehab | 2.1 mi | ★★★★★ | 0 | 0 |
| The Cottage Extended Care | 2.5 mi | ★★★★★ | 0 | 0 |
| Broken Arrow Nursing Home, Inc | 2.6 mi | ★★★★★ | 1 | 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 June 2026) and official state health department websites.