Below 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 Grand Lake Villa during CMS and state inspections, most recent first.
A resident was found touching another resident inappropriately through clothing, and the resident who was touched said no when asked if the contact was okay. The incident was not reported right away to OSDH or law enforcement, and the DON said the facility did not interview staff or residents to see whether other victims existed. The affected resident later became fearful, more isolative, and more agitated, and a psych eval noted increased anxiety and irritability.
A facility failed to implement its abuse policy after an allegation that one resident sexually assaulted another resident. An LPN found one resident touching another resident inappropriately through clothing, the RN separated them, and the resident who was touched said no when asked if the contact was okay. The DON did not report the incident to OSDH or law enforcement at the time, did not interview staff or residents for other potential victims, and instead only directed the two residents to stay apart after deciding with corporate that the abuse policy did not need to be implemented.
A facility failed to thoroughly investigate and report an allegation of sexual abuse involving two residents after staff observed inappropriate touching between them. The DON later stated the incident had not been investigated and was not thought to require reporting. The affected resident was later documented as fearful, not feeling safe, more isolative, and more agitated, with an increase in Zoloft ordered for irritability and anxiety.
Failure to train staff on the facility’s QAPI Program was identified for 103 of 103 employees. The QAPI plan stated that all staff, including contracted staff, are educated on QAPI principles and that QAPI is included in orientation and annual education, but the inservice schedule did not include QAPI. The DON stated the facility had not conducted QAPI training, had no documentation of staff training, and did not find QAPI on the annual training list.
Two residents were involved in arbitration agreements that were signed without clear evidence they understood the documents. One resident with intact cognition said they did not recall authorizing anyone to sign for them, while another resident said they did not receive an explanation and just signed where they were told to sign. The SSD stated they had no training on arbitration agreements and handled them as part of the admission packet.
Arbitration agreements for two residents pre-selected JAMS, or if unavailable NAF, as the arbitration service, rather than providing a neutral and fair process with an agreed-upon arbitrator and venue. The SSD signed the facility representative section of both agreements and stated they had not received training on arbitration agreements and were unaware of the regulations governing them.
SNF ABN Missing Estimated Cost for Non-Covered Services: The facility failed to include the estimated cost on a CMS-10055 ABN for a resident whose representative chose to continue skilled services that might not be covered by Medicare. The form listed PT, OT, daily skilled nursing care, and ST as potentially non-covered services, but the estimated cost section was left blank. The SSD stated the facility left the cost section blank because corporate did not know what amount to enter.
Failure to timely report alleged sexual abuse: an LPN found one resident touching another resident inappropriately through clothing, and an RN separated the residents and confirmed the touched resident did not consent. The DON was notified, but the incident was not reported to OSDH or law enforcement within the required timeframe; the DON later stated the facility and corporate headquarters decided reporting was not necessary.
Inaccurate MDS Fall History: A resident’s quarterly MDS assessment did not accurately capture multiple falls documented in the chart, including several floor-found incidents and one fall with a head hematoma. The care plan listed multiple falls, but the MDS showed only one no-injury fall and no minor-injury falls; the MDS coordinator stated the assessment was not accurate, and the DON said the facility relied on the RAI Manual for MDS accuracy requirements.
A resident with severe cognitive impairment and high care needs was the subject of an abuse allegation. While notifications were made to OSDH, law enforcement, the physician, family, and legal representative, there was no documentation that APS was notified, as required by facility policy. The DON confirmed the lack of APS notification.
A facility failed to report an alleged abuse incident involving a resident within the required two-hour timeframe. A CNA witnessed another CNA cursing and forcibly pulling a resident's hands from a table. The incident was reported to an RN, who did not inform the administration or the DON. The DON learned of the incident two days later, leading to a policy violation.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was protected from sexual abuse when one resident was found touching another resident inappropriately through the resident’s clothing. The resident who was touched had a BIMS score of 14 on a quarterly assessment, indicating intact cognitive abilities. A nursing note documented that staff separated the residents after the incident and asked the resident who was touched whether they were okay with the contact; the resident said no. The incident was not reported to OSDH or law enforcement at the time it occurred. The DON later stated the facility had instructed the two residents to stay away from each other and not eat together, but the DON also stated the facility did not report the incident when it was first known and did not interview staff or residents to determine whether other potential victims existed. The DON said the decision was made with corporate headquarters that reporting was not necessary. Subsequent documentation showed the resident who was touched became fearful, more isolative, and not feeling safe after the incident. A psychiatric evaluation noted the resident appeared more agitated than normal and reported fearfulness, and the resident’s Zoloft was increased because of increased irritability and anxiety. The record also showed the resident who initiated the contact had limited cognition, and staff later documented that the resident who was touched had previously made sexually suggestive comments and advances toward that resident.
Failure to Implement Abuse Policy After Resident-on-Resident Sexual Assault Allegation
Penalty
Summary
The facility failed to implement its abuse policy after an allegation that one resident sexually assaulted another resident. A health status note documented that an LPN found one resident touching another resident inappropriately through the resident’s clothing, and the RN separated the residents and asked the resident who was touched whether they were okay with the other resident touching them; the resident replied, no. The DON was contacted about the incident, and the resident who was touched was described as upset with the restrictions that were later placed between the two residents. The incident was not reported to OSDH or local law enforcement when the facility first learned of it. The DON stated that after learning of the incident, staff did not interview other staff or residents to determine whether there were additional potential victims. Instead, the DON stated the two residents were told to stay away from each other and were not allowed to eat together. The DON also stated that after the incident, the facility contacted corporate headquarters and decided it was not necessary to implement the abuse policy in that situation. The resident involved in the allegation had a quarterly assessment showing a BIMS score of 14, indicating intact cognitive abilities. An initial incident report later documented the event as alleged abuse involving one resident placing a hand on another resident’s private area, and the report noted the incident had occurred earlier but was not reported until much later. The facility’s abuse policy stated that it would protect residents in the case of allegations of abuse and conduct a timely investigation, but those steps were not followed when the allegation was first identified.
Failure to Thoroughly Investigate Alleged Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation of an allegation of sexual abuse involving 1 of 2 sampled residents reviewed for abuse. On 03/11/26, staff observed an LPN witness what was believed to be a sexual act between two residents, and RN #1 later documented that LPN #3 had found one resident touching the other inappropriately through clothing. RN #1 separated the residents and asked the resident who was touched whether they were okay with the contact; the resident replied, no. The DON was contacted about the incident, but the allegation was not thoroughly investigated at that time. The record showed the incident was not reported to OSDH and local law enforcement until 04/22/26, and on 04/23/26 the DON stated that after becoming aware of the alleged sexual abuse, the facility had not investigated it and had decided with corporate headquarters that it did not need to be reported. The facility policy stated it would protect residents in the case of allegations of abuse and conduct an investigation in a timely manner. The failure involved two residents, including one who was later identified as fearful and not feeling safe after the incident. A psychiatric evaluation on 04/24/26 documented that the affected resident appeared more agitated than normal, reported fearfulness and not feeling safe, and had become more isolative since the incident. The note also stated the resident's Zoloft was increased from 50 mg daily to 100 mg daily because of increased irritability and anxiety. The report states the facility identified an Immediate Jeopardy related to the failure to ensure the resident was not sexually assaulted and to thoroughly investigate and report the allegation.
Failure to Train Staff on QAPI
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not provided to all staff. Record review and interview showed the facility failed to ensure staff had been trained in QAPI for 103 of 103 employees identified by the assistant director of nursing. An undated QAPI plan stated that all staff, including contracted staff, are educated on QAPI principles and that QAPI is included in new employee orientation and annual education, but an undated inservice schedule did not include QAPI training. The DON stated on interview that the facility had not conducted any training with all staff on QAPI, had found no documentation that staff were trained in QAPI, and did not find QAPI listed on the annual training list.
Residents Signed Arbitration Agreements Without Clear Understanding
Penalty
Summary
The facility failed to ensure residents understood binding arbitration agreements before signing them for 2 of 2 sampled residents reviewed. For one resident, an arbitration agreement dated 09/29/25 showed the resident representative’s name printed on the signature page, while the SSD signed in the facility representative area. The resident’s admission assessment dated 10/05/25 showed a BIMS score of 15, indicating intact cognition and ability to make decisions of daily living. When interviewed on 04/22/26, the resident stated they did not recall giving anyone permission to sign an arbitration agreement for them and said they were not in their right mind when admitted because of their condition. For the second resident, an arbitration agreement dated 04/08/26 also showed the resident’s name printed in the resident representative section, with no resident signature on the signature page and the SSD signing in the facility representative area. The resident’s admission assessment dated 04/15/26 showed a BIMS score of 14, indicating intact cognition and ability to make decisions of daily living. During interview, the resident stated they did not recall signing an arbitration agreement, did not receive an explanation of what they signed at admission, and said they just signed where they were told to sign. The SSD stated they had not received training on arbitration agreements and oversaw them as part of the admission packet; they also stated they did not recall any resident reading the entire document. The SSD further stated they read the admission documents to the first resident and signed for them because the resident was too shaky at the time.
Arbitration Agreements Pre-Determined the Arbitrator
Penalty
Summary
The facility failed to ensure that binding arbitration agreements did not pre-determine the arbitrator for arbitration proceedings for 2 of 2 sampled residents whose arbitration agreements were reviewed. The arbitration documents for both residents stated that the parties intended Judicial Arbitration and Mediation Services, Inc. (JAMS), or its successor, to serve as the Arbitration Service, and if JAMS was unable or unwilling to serve, the National Arbitration Forum (NAF), or its successor, would serve as the Arbitration Service. Both documents showed the resident's name printed in the resident representative section of the admission agreement signature page, and the SSD signed in the facility representative area. On interview, the SSD stated on 04/22/26 at 8:37 a.m. that they had not received training in arbitration agreements and oversaw them because they were part of the admission paperwork reviewed with new residents. The SSD stated they were unaware of the particulars of the regulations that covered the arbitration agreements. The DON identified that 65 residents resided in the facility.
SNF ABN Missing Estimated Cost for Non-Covered Services
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on record review and interview, the facility failed to include the estimated cost of services on a SNF ABN form CMS-10055 for 1 of 3 sampled residents reviewed for beneficiary notices. The form for Resident #69, dated 03/25/26, showed the resident's representative chose to continue the skilled services listed on the form and acknowledged they may be responsible for the costs if Medicare denied the claim. The services identified as potentially not covered after 04/14/26 were physical therapy, occupational therapy, daily skilled nursing care, and speech therapy, but the section for the estimated cost of those services was left blank. The DON stated 29 residents had been discharged from skilled services within the last six months, and the SSD stated the ABN did not include an estimated cost because corporate did not know what to put since they did not know how much insurance would pay, so the cost section was left blank.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse to the OSDH within the required two-hour time frame for one resident. According to a health status note, an LPN found one resident touching another resident inappropriately through the other resident’s clothing, and an RN separated the residents and asked the resident who was touched whether they were okay with the touching; the resident replied, No. The note also showed the DON was contacted about the incident. An initial incident report later documented that the alleged abuse occurred on 03/11/26 and was not reported to the OSDH and local law enforcement until 04/22/26. During interview, the DON stated the facility did not report the incident at the time it was discovered and that, after discussing it with corporate headquarters, they decided it was not necessary to report it to the OSDH or law enforcement.
Inaccurate MDS Fall History
Penalty
Summary
The facility failed to ensure a quarterly MDS assessment accurately reflected a resident’s fall history. Record review showed that a quarterly assessment dated 01/08/26 documented no falls, even though the resident had already been found lying on the floor on 01/19/26 with no injuries. Additional incident documentation showed the resident was found on the floor again on 02/22/26 and 03/05/26 with no injuries, and on 03/24/26 the resident was found on the locked unit’s television room floor with a small hematoma on the head. A health status note dated 04/09/26 also documented the resident was found lying on the floor after being hit by a door, with no injuries sustained. A quarterly assessment dated 04/10/26 documented only one no-injury fall since the prior quarterly assessment and stated the resident had not had any falls with minor injuries, despite the record showing multiple falls during that period. The care plan revised 04/15/26 listed falls on 01/29/26, 02/22/26, 03/05/26, 03/24/26, and 04/10/26. During interview, the MDS coordinator reviewed the assessment and medical record and stated the care plan showed multiple falls that had not been recorded on the quarterly assessment, and that the assessment was not accurate. The DON stated the facility did not have a policy for MDS assessment accuracy and relied on the RAI Manual for staff requirements.
Failure to Notify APS of Abuse Allegation
Penalty
Summary
The facility failed to notify Adult Protective Services (APS) of an allegation of abuse involving a resident with severe cognitive impairment and dependence on staff for care. Documentation, including a nurse's note and an incident report, showed that the abuse allegation was reported to the Oklahoma State Department of Health (OSDH), local law enforcement, the resident's physician, family, legal representative, and the facility administrator, but there was no evidence that APS was notified. The facility's own policy required that APS be notified of such allegations, and the Director of Nursing confirmed that there was no documentation of APS notification for this incident.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical and verbal abuse involving a resident within the required two-hour timeframe. According to the facility's Abuse Investigating and Reporting policy, any alleged violation involving abuse must be reported immediately, but not later than two hours if it involves abuse or results in serious bodily injury. In this case, an incident report documented that the alleged abuse occurred on June 8, 2024, but was not reported to the Director of Nursing (DON) until June 10, 2024. This delay in reporting was a violation of the facility's policy. The incident involved a Certified Nursing Assistant (CNA) who allegedly cursed at a resident and forcibly pulled the resident's hands from their grip on a table. Another CNA witnessed the incident and reported it to a Registered Nurse (RN) approximately 45 minutes later. However, the RN failed to inform the administration or the DON about the allegation. The DON only became aware of the incident when the witnessing CNA reported it on June 10, 2024. The RN was subsequently disciplined for not following the facility's abuse reporting policy.
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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 Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Betty Ann Nursing Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Grove Nursing Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Monroe Manor | 10.6 mi | ★★★★★ | 0 | 0 |
| Maple Healthcare And Rehab | 12.4 mi | ★★★★★ | 0 | 0 |
| Mcdonald County Living Center | 19 mi | ★★★★★ | 0 | 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.