Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Green Country Care Center during CMS and state inspections, most recent first.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
A facility failed to obtain consent from a resident's POA before administering a flu vaccine. The resident, who had severe cognitive impairment, was given the vaccine despite the POA's prior instruction against further vaccinations. The DON acknowledged that the POA's request was not documented or communicated, resulting in the unauthorized administration.
The facility did not provide residents with accessible notifications of their rights, ombudsman contact information, and state agency contact information. Residents were unaware of where to find this information, which was posted in a locked vestibule and inside the nurses' station, both inaccessible to them. The administrator confirmed these postings and acknowledged the inaccessibility for residents.
The facility failed to provide necessary information for advance directives to three residents, as required by policy. Two residents lacked documentation of being offered advance directives, and a third resident with dementia had no record of discussions about advance directives, despite being a full code status. The admissions coordinator was unaware of the need to document these discussions.
The facility failed to provide advance beneficiary notices (ABNs) to two residents with dementia when their skilled services ended. Although the Notice of Medicare Non-Coverage (NOMNC) was given, the residents continued in long-term care without documented ABNs. The admissions coordinator admitted to verbally notifying representatives but did not document it, and the administrator acknowledged the need for training on beneficiary notices.
A resident with dementia was discharged and returned from the hospital, but the facility failed to complete an entry assessment upon their readmission. MDS coordinators acknowledged the oversight, noting that while discharge assessments were tracked, entry/re-entry assessments were not monitored.
The facility failed to update care plans for two residents with dementia, leading to deficiencies in care. One resident's care plan did not address their skin-picking behavior, resulting in untreated wounds. Another resident's care plan failed to document their frequent refusal of showers, despite staff observations and records indicating this behavior. MDS coordinators were unaware of these issues, leading to a lack of necessary updates in the care plans.
A resident with dementia, requiring supervision for bathing, refused showers 17 times over a month. Despite documented refusals, no interventions were implemented, and staff were unaware of the frequency. Observations noted a persistent urine/body odor in the resident's room.
The facility failed to date opened medications on a medication cart, including eye drops and nasal sprays for several residents. An LPN and the DON confirmed that these medications should be dated when opened.
A facility failed to maintain infection control when an LPN was observed blowing on a resident's food before feeding. The LPN acknowledged this was against protocol, and the DON confirmed that staff should allow food to cool naturally instead.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Obtain Consent for Flu Vaccination
Penalty
Summary
The facility failed to ensure that a resident or their legal representative received education regarding the benefits and potential side effects of the influenza immunization and obtain consent before administering the immunization. This deficiency involved a resident with severe cognitive impairment due to dementia and anxiety, whose family member was designated as the power of attorney (POA). The family member had previously informed the facility in 2023 that they did not wish for the resident to receive any further vaccines. However, in October 2024, the resident was administered a flu vaccine without the consent of the family member. The Director of Nursing (DON) confirmed that the POA's request was not documented in the resident's record, nor was it communicated to the relevant staff, leading to the administration of the vaccine without consent.
Inaccessible Resident Rights and Contact Information
Penalty
Summary
The facility failed to provide residents with accessible notifications of their rights, ombudsman contact information, and state agency contact information. During a resident council meeting, five residents expressed that they were unaware of where to find the phone number for the ombudsman, the location of the posted resident rights, or how to contact the Oklahoma State Department of Health (OSDH) to register a complaint or concern. Observations revealed that the notices were posted in a locked vestibule by the facility's front door and inside the nurses' station along the far wall. The locked vestibule was not accessible to residents, and the notices inside the nurses' station were not readable from the hallway. The administrator confirmed that the information was posted in these locations and acknowledged that residents were not permitted inside the nurses' station, making the notices inaccessible to them.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information necessary for residents to formulate an advance directive, as required by their policy. This deficiency was identified for three residents who were reviewed for advance directives. The facility's policy, dated December 2016, mandates that upon admission, residents should be given written information about their right to formulate an advance directive. However, for Residents #22 and #71, there was no acknowledgement form for an advance directive in their electronic records. The admissions coordinator confirmed the absence of documentation indicating that advance directives were offered to these residents. Additionally, Resident #66, who had a diagnosis of dementia and was documented as having a full code status, also lacked documentation of being provided information to formulate an advance directive. The admissions coordinator was unaware of the need to document the offering of advance directives. Despite the administrator stating that the admission packet contained information about advance directives, there was no documentation of discussions regarding advance directives with Resident #66 or their representative.
Failure to Provide Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide advance beneficiary notices (ABNs) to two residents who were reviewed for beneficiary notices. Resident #22, diagnosed with dementia, had their last covered day of Part A services on 06/13/24, and the facility initiated the discharge from skilled services without providing an ABN. Although the Notice of Medicare Non-Coverage (NOMNC) indicated that the resident or their representative was notified of the change in services on 06/12/24, the resident continued to stay in the facility for long-term care after skilled services ended. Similarly, Resident #47, also diagnosed with dementia, had their last covered day of Part A services on 08/29/24, and the facility initiated the discharge from skilled services without providing an ABN. The NOMNC documented that the resident or their representative was notified of the change in services on 08/29/24, yet the resident remained in the facility for long-term care. The admissions coordinator admitted to only providing the NOMNC when residents were discharged from skilled services and acknowledged that they verbally notified the representatives for both residents but failed to document the notification. The facility administrator recognized the oversight in providing ABNs and identified a need for training on beneficiary notices.
Failure to Complete Entry Assessment for Returning Resident
Penalty
Summary
The facility failed to ensure that assessments were encoded and transmitted for a resident who was reviewed for assessments. The resident, who had a diagnosis of dementia, was discharged with a return anticipated assessment dated 09/10/24 and returned from the hospital on 09/11/24. However, upon readmission, an entry assessment was not completed, as revealed by a review of the electronic clinical record. The next documented assessment was an in-progress quarterly assessment. MDS coordinators acknowledged that the entry assessment for the resident's return on 09/11/24 was overlooked. They admitted to using a tracking form for monitoring discharge assessments but did not monitor for entry/re-entry assessment completion.
Failure to Update Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to update the care plan for two residents, both diagnosed with dementia, leading to deficiencies in their care. Resident #22 had a care plan dated 09/05/24 that did not address their behavior of skin picking, despite observations of open wounds on their neck, forehead, and hands. LPN #2 confirmed the resident's habit of picking at their skin, which was not reflected in the care plan until 11/14/24. MDS Coordinator #1 acknowledged that the care plan was updated on 11/14/24 but had not included the skin-picking behavior prior to that date. Resident #128's care plan was also found lacking, as it did not document the resident's refusal of showers or care, despite records showing they refused showers 17 times out of 22 opportunities. Observations noted a urine/body odor in the resident's room, and staff, including CNA #1, the DON, and the ADON, confirmed the resident's history of refusing care. MDS coordinators were unaware of the refusals and had not updated the care plan to reflect this behavior.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for bathing, received adequate assistance with activities of daily living (ADL). The resident, diagnosed with dementia, was documented to require supervision and touch assistance for bathing and toileting. Despite this, the resident refused showers 17 times out of 22 opportunities between early October and mid-November. The CNA Shower Skin Observation Tool forms noted these refusals but did not document any interventions to prevent recurrence. Observations on multiple occasions noted a urine/body odor in the resident's room, indicating a lack of proper hygiene care. Interviews with staff revealed that the resident had a history of refusing care, including showers and linen changes, and that the family was sometimes called for assistance. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the resident's refusals but were unaware of the frequency. The ADON stated that they and the charge nurse were responsible for reviewing shower sheets to ensure residents received ADL assistance, but interventions were not implemented despite documented refusals.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to ensure that medications were dated when opened, as observed on the North hall medication cart. During an inspection, it was found that several medications, including neomycin/polymyxin 0.1% eye drops for one resident and fluticasone nasal spray 50mcg for three other residents, were open but not dated. This observation was made in the presence of an LPN, who acknowledged that nasal sprays and eye drops should be dated upon opening. The Director of Nursing (DON) also confirmed that the practice is to date these medications when opened.
Infection Control Breach During Meal Assistance
Penalty
Summary
The facility failed to maintain infection control during meal assistance for a resident. During an observation, an LPN was seen blowing on a spoonful of food before feeding it to a resident. This action was contrary to infection control protocols, as confirmed by the LPN, who acknowledged that staff should not blow on residents' food. The Director of Nursing (DON) later stated that if food was hot, staff were instructed to let it cool down naturally before feeding it to residents, rather than blowing on it.
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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 Tulsa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Simeons Episcopal Home | 2.9 mi | ★★★★★ | 0 | 0 |
| Oklahoma Memory Care Institute | 5.8 mi | ★★★★★ | 2 | 0 |
| Trinity Woods, Inc. | 6.1 mi | ★★★★★ | 0 | 0 |
| Emerald Care Center Tulsa | 6.5 mi | ★★★★★ | 4 | 0 |
| Gracewood Health & Rehab | 7 mi | ★★★★★ | 9 | 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.