Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland Park Health Care during CMS and state inspections, most recent first.
Undated food items and improperly kept leftovers were found in the kitchen refrigerator. Several opened and unopened items, including lunch meat, chicken, cheese, sauces, and sausage patties, lacked dates, and a container of Mexican soup remained in the refrigerator past the facility's stated storage time. The NSM, RD, DON, and Administrator all stated food items were expected to be dated when received and opened, and leftovers were expected to be discarded per policy.
A resident with an indwelling catheter and intact cognition had a urinary drainage bag left uncovered and visible from the hallway, with yellow urine seen inside the bag. The resident said the exposed bag bothered them, and staff including an LPN and the DON stated the bag should have been covered in a privacy bag for dignity purposes.
A DON changed a resident’s code status to DNR in the EMR without speaking with the resident first, despite the resident having intact cognition and later stating they wanted resuscitation. The chart contained conflicting code status documentation, including Full Code and DNR entries in the admission record, care plan, and physician orders.
A resident with dementia and severe cognitive impairment had an order for sodium chloride nebulizer treatments for congestion, and an LPN administered the treatment during observation. However, the resident's care plan did not include congestion or nebulizer use, and the LPN, MDS Coordinator, DON, and Administrator all acknowledged that no care plan addressing the treatment was in place.
Failure to supervise a resident during a nebulizer treatment. A resident with dementia and severe cognitive impairment was receiving ordered inhaled sodium chloride for congestion, but an LPN left the room during the treatment more than once. While unattended, the resident removed the mask and turned off the machine. The ADON and DON stated a nurse was required to stay with the resident during breathing treatments, and the resident had no assessment showing ability to self-administer.
Medication Administration Error Rate Exceeded Threshold: An LPN made insulin administration errors while giving injections to a resident with type 1 DM and hyperglycemia. The nurse dialed and pushed the pen before attaching the needle, then set the dose afterward, and removed both injections immediately instead of waiting the required seconds. The facility’s error rate was 6.45%, above the expected threshold.
Inconsistent Code Status Documentation: A resident’s chart contained conflicting code status entries across the admission record, care plan, physician orders, telephone orders, progress notes, and care conference minutes, with both Full Code and DNR documented in different places. The resident had intact cognition, and a DNR alert was also posted on the closet door. The DON, MDS Coordinator, and DO all acknowledged the inconsistency and its impact on staff understanding of the resident’s code status.
Unsafe Storage and Maintenance of Sit-to-Stand Mechanical Lift: A sit-to-stand mechanical lift was found stored in a shower room despite manufacturer guidance against damp storage. Staff observed peeling paint, a missing screw/bolt, instability of the handles, rust-like residue, and debris and hair in the wheels. The ADON and RDPO both identified missing components and stated the lift should not have been in service, while the DON described the condition as unacceptable.
Daily nurse staffing information was not accurately completed or posted for staff directly responsible for resident care. The posted staffing sheets contained blank census fields and missing actual hours worked, with several days showing only scheduled hours instead of actual staffing data. An LPN, the Staffing Coordinator, the DON, and the Administrator all described expectations that the census and actual hours should be completed accurately on the staffing form.
A resident with significant communication and memory impairments was physically and psychosocially abused by a CNA during care, as witnessed and reported by a roommate. The resident displayed distress and fear following the incident, and the event was confirmed through interviews and assessment by the DON.
The facility failed to maintain proper food storage and sanitation in the kitchen, affecting 77 residents. Observations revealed unlabeled and uncovered food items in the refrigerator and unsanitary conditions throughout the kitchen. Staff interviews confirmed non-compliance with cleaning schedules and food storage policies, and the Administrator acknowledged the kitchen's unsanitary state.
A resident with diabetes experienced multiple instances of elevated blood sugar levels that exceeded the physician-ordered parameters. Despite the facility's policy requiring physician notification for out-of-range glucose levels, there was no documentation that the physician was contacted. The DON confirmed that nurses should follow orders and notify the physician when blood sugar levels are out of parameter.
A facility failed to ensure a psychotropic medication was used for a specific diagnosis for a resident. The resident, diagnosed with dementia without psychotic disturbance and major depressive disorder, was prescribed olanzapine, an antipsychotic, for major depressive disorder without psychotic features. A quarterly assessment showed no indicators of psychosis, and the DON confirmed there was no diagnosis justifying the antipsychotic use.
Undated Food Items and Improperly Kept Leftovers in Refrigerator
Penalty
Summary
The facility failed to ensure food was labeled appropriately and failed to ensure leftovers were discarded according to facility procedures. Facility policy required foods in storage to be covered, labeled, and dated, and required food subject to spoilage to be sealed, labeled, and dated when removed from its original container. The Nutrition Services Manual also listed refrigerator storage times for foods such as soups and stews with vegetable and meat added as 3 to 4 days. During a kitchen observation, several items in the reach-in refrigerator were found undated, including unopened sliced lunch meat, opened diced chicken, opened shredded mild cheddar cheese, unopened sausage patties, opened barbeque sauce, opened chocolate syrup, and opened ketchup. In the same refrigerator, a metal container covered with aluminum foil was labeled Mexican Soup and dated 06/08/2026. A DA stated food had to be labeled with the date received and, if opened, the received date and date opened. The NSM and RD stated the undated items should have been dated and the Mexican soup should have been thrown away. The DON and Administrator stated their expectation was that food items be dated and removed at the correct times.
Uncovered urinary catheter bag visible from hallway
Penalty
Summary
The facility failed to ensure Resident #7’s right to a dignified existence when the resident’s urinary catheter drainage bag was left uncovered and visible from the hallway. Resident #7 was admitted on 09/12/2023 and had a diagnosis of neuromuscular dysfunction of the bladder. The resident’s significant change MDS showed a BIMS score of 15, indicating intact cognition, and the resident had an indwelling catheter with continuous gravity drainage. The resident’s plan of care identified the indwelling catheter, but it did not include interventions for covering or placing the catheter bag. During a concurrent observation and interview on 06/15/2026, the drainage bag was hanging on the bed and facing the door with yellow urine visible from the hallway, and Resident #7 stated it bothered them that the urine bag was exposed. The resident also stated staff sometimes placed the drainage bag in a privacy bag and that the privacy bag was at the bedside hanging on the wheelchair. A later observation on 06/16/2026 again found the room door open and the catheter drainage bag visible from the hallway hanging on the bedframe. An LPN stated the privacy bag was important for dignity purposes and that Resident #7 should have had the drainage bag in a privacy bag on both occasions. The DON also stated it was important to cover a urinary collection bag for dignity purposes and expected Resident #7’s drainage bag to be placed in a privacy bag.
Failure to Confirm Resident Code Status Before Changing Orders
Penalty
Summary
The facility failed to communicate with a resident before changing the resident’s code status from Full Code to DNR. Resident #3 was admitted with code status listed as Full Code and DNR in the admission record, and the quarterly MDS showed a BIMS score of 15, indicating intact cognition. The resident’s plan of care contained conflicting documentation, including statements that the resident had chosen to be DNR, while physician orders also listed Full Code and DNR entries on the chart. During interviews, Resident #3 stated they had previously not wanted resuscitation but now wanted to be resuscitated, and later confirmed they had not spoken with facility staff that morning about their resuscitation wishes. The DON stated she entered the physician’s DNR order into the EMR that morning to clean up the resident’s dual code status and did so without speaking with the resident first. The Administrator stated that code status must be correct and that this was the expectation.
Failure to Care Plan Nebulizer Treatment and Congestion
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident's respiratory condition and the use of a nebulizer breathing treatment. Resident #72 was admitted with diagnoses including unspecified dementia and unspecified lack of coordination, and an annual MDS showed a BIMS score of 3, indicating severe cognitive impairment. The resident had an active order for sodium chloride 0.9% solution, one vial inhalation three times a day for congestion. During observation, an LPN prepared and administered a nebulizer treatment by adding sodium chloride to a medication canister and applying the mask to the resident. However, the resident's current plan of care did not include a focus area or interventions related to congestion or nebulizer use. The LPN stated she expected a care plan for nebulizer treatment and confirmed none was present. The MDS Coordinator stated she had not thought of adding a care plan for nebulizer treatments and said she only added care plans for diagnoses related to nebulizer use. The DON and Administrator both stated they expected a care plan for nebulizer treatment, and the DON confirmed the resident did not have a care plan addressing congestion or nebulizer use.
Failure to Supervise Nebulizer Treatment
Penalty
Summary
The facility failed to ensure a resident in the memory care unit was supervised during a nebulizer treatment. Resident #72 was admitted with diagnoses including unspecified dementia and unspecified lack of coordination, and the annual MDS showed a BIMS score of 03, indicating severe cognitive impairment. The resident’s active orders included sodium chloride 0.9% solution inhaled three times a day for congestion, and there was no order for self-administration of medical treatments. The resident’s plan of care did not include a focus area for nebulizer use, respiratory treatment, or self-administration of medical treatments. During observation, an LPN prepared the nebulizer treatment and applied the mask to the resident, then walked away from the room while the treatment was still in progress. While the LPN was away, the resident removed the mask, placed it on the bedside table with medication still in the chamber, and turned off the machine. The LPN later returned and reapplied the mask, then again left the room during the treatment. The ADON stated a nurse was required to stay with the resident during breathing treatments and that the LPN should not have walked away in the memory care unit. The LPN stated the resident could not self-administer medications and had no assessment showing capability to administer the treatment when the nurse walked away.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication administration error rate remained below 5 percent. Surveyors identified 2 medication errors out of 31 opportunities, resulting in a 6.45% error rate and affecting 1 resident reviewed during the medication administration task. Facility policy stated medications are to be administered as prescribed and in accordance with written orders of the prescriber. Resident #2 was admitted with a history of type 1 diabetes mellitus with hyperglycemia. The resident’s MDS showed intact cognition with a BIMS score of 15 and indicated daily insulin use during the lookback period. The resident’s plan of care directed staff to administer diabetic medications as ordered. Active orders included Novolin R FlexPen 7 units subcutaneously every six hours and Novolog FlexPen per sliding scale before meals and bedtime. During medication administration observation, an LPN opened the Novolog FlexPen and, before applying a needle, turned the dial to an unknown amount, pushed the button, then applied the needle and turned the dial to 8 units. The same process occurred with the Novolin R FlexPen, with the dial turned to an unknown amount and pushed before the needle was applied, then turned to 7 units. The LPN also removed both injections immediately without waiting the required six seconds. The LPN stated this was how she had been trained. Another LPN stated the needle should be primed before setting the dose. The DON stated the expected medication error rate was 0%, that the needle should be primed before dialing to the ordered dose, and that staff should wait three to five seconds before removing the needle to ensure the full dose was administered.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure an accurate code status was reflected throughout the medical record for one resident who was reviewed for advance directives. The resident was admitted with conflicting documentation in the record, including an admission record listing both Full Code and DNR, while a quarterly MDS showed intact cognition with a BIMS score of 15. The resident’s current care plan contained inconsistent entries, with one section stating the resident had chosen to be DNR and another section stating Full Code; DNR at the bottom of each page. Physician orders and telephone orders also contained conflicting code status information, including orders for Full Code, discontinuation of Full Code, and later DNR entries, with code status language appearing inconsistently across the record. Additional documentation continued to show the inconsistency. Care plan conference/discharge planning minutes recorded that code status was discussed, but listed Full Code; DNR. Interdisciplinary progress notes over multiple months stated the resident remained Full Code. At the same time, a red Medical Alert DNR sheet was observed inside the resident’s closet door. During interviews, the DON stated the inconsistent code status could result in the resident not receiving resuscitation if they wanted it or receiving resuscitation when they did not want it. The MDS Coordinator stated she updated the care plan and MDS reports but did not review physician orders when completing that process, and the DO stated that if the care plan was confusing for staff, a resident who needed to be coded might not be coded.
Unsafe Storage and Maintenance of Sit-to-Stand Mechanical Lift
Penalty
Summary
The facility failed to ensure 1 of 3 mechanical lifts was maintained in safe working condition and stored according to manufacturer instructions. Facility policy stated maintenance service was to keep equipment in a safe and operable manner, and the lift manufacturer’s manual instructed that the lift should not be stored in a damp area and that damaged or corroded parts should be inspected and addressed. Staff interviews confirmed that mechanical lifts were stored in shower rooms, which the Regional Director of Plant Operations described as damp environments due to steam, condensation, and humidity. During observation, the sit-to-stand mechanical lift was found in a shower room with peeling paint, a missing screw, instability of the handles, reddish-brown residue, and debris and hair in the wheels. The Assistant Director of Nursing stated the lift was missing a bolt and should not have been in service, and the observation later showed a Do Not Use tag on the lift. The Regional Director of Plant Operations also identified a missing pin in the mast supporting the actuator and battery, and the Director of Nursing stated the rust, dirt, and hair on the lift were unacceptable. The Administrator stated malfunctioning equipment should be reported immediately and stored according to facility policy and manufacturer guidance, but the lift had been kept in the shower room when not in use.
Daily nurse staffing information was not accurately completed or posted
Penalty
Summary
The facility failed to ensure the daily nurse staffing information was accurately completed and posted for staff directly responsible for resident care for 17 of 17 days reviewed from 06/01/2026 through 06/17/2026. A facility policy titled, Daily Nurse Staffing Information, required the daily staffing sheet to be posted in a public area and to include the facility name, current date, resident census, actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, and calculated FTEs based on an 8-hour shift. The policy also required the staffing sheet to be corrected as needed for staffing changes occurring throughout the 24-hour period. Observations at the nurses' station on 06/15/2026, 06/16/2026, and 06/17/2026 showed the posted Daily Staffing Sheet-Clinical Department had the census left blank. Review of the staffing sheets for 06/01/2026 through 06/17/2026 showed multiple omissions, including sheets that contained only scheduled nursing hours rather than actual hours worked, with census and total hours for shifts left blank on several days. During interviews, an LPN stated the census should be filled in and actual hours worked should be completed, the Staffing Coordinator stated she did not fill out actual hours because she was not sure if staff called in and that she received very little training on the form, and the DON and Administrator stated the sheet was expected to reflect accurate hours and census totals.
Failure to Prevent Physical and Psychosocial Abuse of a Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical and psychosocial abuse. The resident, who was nonverbal, had aphasia, memory problems, and was rarely or never understood. During morning rounds, the housekeeping supervisor noticed the resident appeared sad and, upon inquiry, the resident's roommate reported that a nurse aide had slapped the resident during care on the night shift. The resident confirmed the abuse by nodding and pointing to the left side of their face. The incident was reported to the Director of Nursing (DON), who conducted interviews and a head-to-toe assessment, which revealed no physical injuries. Following the incident, the resident exhibited fear and distress, particularly when night shift staff attempted to provide care, and began receiving psychological counseling. The roommate recounted hearing the resident become increasingly upset, followed by a loud slap, and observed the resident crying after the aide left the room. The facility's policy prohibits abuse, neglect, and exploitation by anyone, including staff, but this policy was not upheld in this instance, resulting in the resident experiencing both physical and psychosocial harm.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper food storage and sanitation practices in the kitchen, affecting the nutrition services provided to 77 residents. During an inspection, it was observed that clean dishware was not stored inverted or on sanitary surfaces, and the kitchen was not maintained in a clean and sanitary condition. Specific issues included uncovered and unlabeled cooked pork loin, raw pork loin, and raw chicken in the walk-in refrigerator, all without proper dating. Additionally, various areas in the kitchen, such as the griddle area, food preparation area, and cereal station, were found with food debris, sticky substances, and unsanitary conditions. Interviews with kitchen staff and the Certified Dietary Manager (CDM) revealed a lack of adherence to the facility's policies regarding food storage and kitchen cleanliness. The staff acknowledged that the kitchen was not cleaned properly, and the CDM confirmed that the cleaning schedule was not being followed. The facility's Administrator expressed disappointment upon reviewing the kitchen's condition, agreeing that it was not clean or sanitary and that items in the refrigerator should have been labeled with the date they were opened.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician for out-of-parameter blood sugar levels for a resident with diabetes, as required by the physician's orders. The resident's blood sugar levels exceeded the established threshold on multiple occasions in June, July, and August, yet there was no documentation indicating that the physician was contacted. Specifically, the resident's blood sugar levels were recorded as being above 350 in June and July, and above 501 in August, without any corresponding notification to the physician. The facility's policy on Bedside Blood Glucose Monitoring, revised in February 2020, mandates that the physician be contacted if glucose levels fall outside the established ranges. Despite this policy, the facility did not adhere to the protocol, as evidenced by the lack of documentation of physician notification for the resident's elevated blood sugar readings. The Director of Nursing confirmed that nurses are expected to follow the physician's orders and contact the physician for guidance when blood sugar levels are out of parameter.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a psychotropic medication was used for a specific diagnosis for one resident who was reviewed for unnecessary medication. The resident had diagnoses including dementia without psychotic disturbance, cerebrovascular disease, and major depressive disorder. Despite this, the resident was prescribed olanzapine, an antipsychotic medication, for major depressive disorder without psychotic features. A quarterly assessment noted that the resident was receiving an antipsychotic medication but documented no potential indicators of psychosis or behaviors. The care plan required staff to monitor for behaviors and side effects of the medication every shift, but the Director of Nursing (DON) confirmed that there was no diagnosis justifying the use of an antipsychotic medication for this resident.
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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 Okmulgee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlands Skilled Nursing And Therapy | 0.9 mi | ★★★★★ | 2 | 0 |
| Heartway At Henryetta Health And Rehab | 10.9 mi | ★★★★★ | 0 | 0 |
| Fountain View Manor, Inc | 12.7 mi | ★★★★★ | 7 | 0 |
| Haskell Care Center | 21.3 mi | ★★★★★ | 0 | 0 |
| Rainbow Terrace Care Center | 21.7 mi | ★★★★★ | 0 | 0 |
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