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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medical Park West Rehabilitation & Skilled Care during CMS and state inspections, most recent first.
Two residents experienced significant medication errors when a nurse incorrectly transcribed admission orders, resulting in each resident receiving the other’s medications for an extended period. One resident with atrial fibrillation and a moderately impaired BIMS score did not receive ordered Eliquis, Famotidine, Culturelle, and an antibiotic, but instead received antidepressant, antihypertensive, cholesterol, and thyroid medications intended for another resident. The second resident, with hypertension and intact cognition, did not receive prescribed antidepressant, multiple antihypertensives, thyroid, cholesterol, pain, and steroid medications, and instead received Eliquis, Famotidine, and Culturelle. The same nurse entered and reviewed both sets of orders, and the ADON and clinical team did not double-check the drug regimen review. Additionally, BP medication with ordered hold parameters was administered to one resident despite a BP reading below the specified threshold.
A resident with a seizure disorder and multiple comorbidities did not receive several ordered doses of Levetiracetam, resulting in seizure activity and hospitalization for emergency treatment. The DON was unaware of the medication error or the reason for the resident's ER visit at the time.
A resident dependent on dialysis did not have consistent pre- and post-dialysis monitoring documentation as required by facility policy, with only one pre-dialysis report found during a review period when multiple sessions occurred. The DON confirmed that documentation should have been completed for each dialysis session.
A resident with multiple chronic conditions experienced bladder pain and had a urinalysis performed, which was within normal limits. Although the patient and family were informed of the results, there was no documentation that the physician was notified as required by facility policy. The resident was later sent to the ER and diagnosed with a urinary tract infection. The DON confirmed the policy was not followed.
A facility failed to monitor a resident's bowel movements and conduct daily skilled nursing assessments. The resident, with a history of vertebrae fracture and pulmonary fibrosis, had a care plan for elimination issues but lacked documented interventions after three days without a bowel movement. Additionally, daily assessments were not completed on three occasions, contrary to facility expectations.
The facility failed to complete baseline care plans for several residents with significant medical conditions, including congestive heart failure and diabetes mellitus with chronic kidney disease. The absence of these care plans was confirmed through record reviews and an interview with the DON, highlighting a lapse in meeting residents' immediate needs upon admission.
The facility failed to monitor weights and meal intake as ordered for four residents, leading to inconsistent documentation and significant weight loss. A resident with cerebral infarction and underweight was not weighed weekly as ordered, and meal intake was poorly documented. Another resident with a femur fracture also had inconsistent meal intake records. A resident with diabetes and chronic kidney disease was weighed only once a month, and meal intake was sparsely recorded. A resident with cerebral infarction experienced significant weight loss due to inadequate monitoring. Staff interviews revealed a lack of supervision and adherence to facility policies.
The facility failed to label and store medications properly, leading to a mix-up of insulin pens for two residents and unsecured storage of liquid Ativan for a deceased resident. The ADON was unaware of the Ativan's presence due to a lack of narcotic count sheets from a hospice pharmacy, resulting in inadequate medication reconciliation.
The facility did not provide proper beneficiary notifications to two residents who remained in the facility as LTC residents after being discharged from skilled services. Both residents had skilled days remaining but were not given an ABN. The social services director admitted to not providing the ABNs, assuming the MDS coordinator had done so, and the administrator confirmed a lack of training on beneficiary notifications.
A facility failed to complete a quarterly assessment for a resident with hypertension, as required every three months. The last quarterly assessment was in June, followed by an annual assessment in September, with no further assessments documented. The MDS coordinator could not explain the oversight, and the DON confirmed the assessment should have been done.
The facility failed to encode and transmit assessments for two residents. A resident with hypertension was discharged without a completed discharge return not anticipated assessment. Another resident with paraplegia had discharge return anticipated assessments but lacked re-entry assessments upon returning to the facility. The DON and MDS coordinator acknowledged the oversight, noting the previous MDS coordinator's failure to complete required assessments.
A facility failed to complete a discharge summary for a resident with hypertension, who was discharged to home. The discharge summary was missing a recapitulation of the resident's stay, with only dietary and activities sections filled out. The DON acknowledged the incomplete summaries and the responsibility of each department to complete their sections.
A facility failed to consistently assess a resident's dialysis access site after dialysis sessions, as required by policy. The resident, with end-stage renal disease, was scheduled for dialysis three times a week. Despite the policy and physician's orders, documentation showed that post-dialysis assessments were not consistently performed. Interviews with staff revealed that staffing changes contributed to the inconsistency in completing the required assessments.
A facility failed to conduct monthly medication reviews and address pharmacist recommendations for a resident with chronic pain. The consultant pharmacist's recommendation to adjust gabapentin dosage was not addressed for several months, and the December 2024 medication review was missing. The DON acknowledged the oversight in addressing the pharmacist's recommendation.
A resident with diabetes mellitus did not receive scheduled laboratory tests as ordered by their physician. The facility was supposed to conduct a CBC every six months and a hemoglobin A1C every three months, but these tests were not completed as required. The DON indicated that the ADON was responsible for ensuring the completion of these tests, but they were not entered into the lab company's ordering system.
A facility failed to implement Enhanced Barrier Precautions (EBP) during the treatment of a resident's stage 2 pressure ulcer. The wound care nurse did not wear a gown as required by the facility's policy, which mandates EBP for residents with wounds. Misunderstandings about the policy led to inadequate infection control measures.
Transcription Errors and Failure to Follow BP Parameters Lead to Significant Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and administration of admission medication orders for two residents, resulting in significant medication errors. For one resident admitted from the hospital with discharge orders for Eliquis, Famotidine, Culturelle, and Linezolid, the facility’s medication record shows these ordered medications were not administered for multiple days following admission. Instead, this resident received Duloxetine, Amlodipine, Atorvastatin, Levothyroxine, and Valsartan over the same period, which were not part of the hospital discharge medication list for that resident. The resident had diagnoses including atrial fibrillation and wound infection, and an admission assessment documented moderately impaired cognition with a BIMS score of 11. The second resident’s hospital discharge medication list included Duloxetine, Amlodipine with specific blood pressure hold parameters, Atorvastatin, Levothyroxine, Valsartan, Celecoxib, and Prednisone. However, the medication record shows this resident did not receive these ordered medications for an extended period after admission. Instead, the resident received Eliquis, Famotidine, and Culturelle, which were not on this resident’s hospital discharge list but were ordered for the first resident. An admission assessment documented that this resident had diagnoses including hypertension and osteoporosis and had intact cognition with a BIMS score of 13. Record review and interviews revealed that both residents were admitted on the same day and that the same nurse entered the medication orders for both residents and completed the drug regimen review. The facility’s root cause analysis documented that the medications intended for the second resident were entered on the first resident’s orders, and vice versa, and that the ADON and clinical team did not double-check the orders or recheck the drug regimen review. Additionally, the medication administration record for the first resident showed that Amlodipine was not held when the blood pressure reading was 105/69, despite physician-ordered parameters to hold the medication for systolic blood pressure below 110, diastolic below 60, or pulse below 60. Staff interviews confirmed that the orders were switched during entry, that another nurse did not double-check the orders, and that blood pressure medications with hold parameters should be held when readings are below those parameters.
Failure to Administer Anticonvulsant as Ordered Leads to Seizure and Hospitalization
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one of seven sampled residents reviewed for significant medication errors. Specifically, a resident with a history of seizures, chronic kidney disease, dependence on dialysis, hypothyroidism, cardiomegaly, and atherosclerotic heart disease had a physician order for Levetiracetam 500 mg to be given every 12 hours for seizure control. The medication administration record showed that 9 out of 26 morning doses of Levetiracetam were missed over a period of less than a month. As a result of these missed doses, the resident experienced seizure activity and required emergency department intervention, where IV Levetiracetam was administered. Documentation indicated that the resident returned from the hospital after receiving treatment for seizures, and it was noted that future medication administration would be adjusted to occur prior to dialysis. The DON was not aware of the reason for the resident's emergency room visit or the significant medication error at the time of the incident.
Removal Plan
- Regional Nurse Consultant will educate the Director of Nursing on identification of significant medication errors and administration of medication per physician orders.
- Director of Nursing/Designee will educate all licensed nurses and certified medication aides regarding administering medication according to physician orders and identification of significant medication errors.
- Medication aides and Licensed nurses will document medication administration in the eMAR.
- Any licensed nurse or certified medication aide not educated will not be allowed to work until they have received education.
- An audit of current residents missing significant medications for the last 7 days was conducted and completed by nursing management to assure that significant medications are given as ordered by physician.
- Any significant medication errors found during the audit will be reviewed by the Director of Nursing.
- The medical director will be notified of the findings for any further recommendations.
Failure to Complete Required Pre- and Post-Dialysis Monitoring Documentation
Penalty
Summary
The facility failed to ensure that residents receiving dialysis had proper pre- and post-dialysis monitoring as required by policy. Specifically, for one resident with a diagnosis of dependence on dialysis and a physician's order for dialysis three times per week, the medical record review over a nearly one-month period revealed only one pre-dialysis communication report. The facility's policy required completion of pre- and post-dialysis forms for each dialysis session, but this was not consistently done. The Director of Nursing confirmed that the required documentation should have been present for every dialysis day, indicating a lapse in following established procedures for monitoring residents before and after dialysis sessions.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to ensure timely physician notification of laboratory results for a resident who complained of bladder pain and pressure. A urinalysis (UA) was ordered and obtained, with results reported as within normal limits (wnl). Although the patient and family were informed of the normal UA results, the medical record did not show documentation that the physician was notified of these results, as required by facility policy. The resident, who had a history of atrial fibrillation, heart failure, and hypertension, was subsequently sent to the emergency room at the insistence of the patient and family, and was later diagnosed with a Pseudomonas urinary tract infection. The Director of Nursing confirmed that the facility policy regarding physician notification was not followed and that there was no documentation of physician notification in the medical record.
Failure to Monitor Bowel Movements and Conduct Daily Assessments
Penalty
Summary
The facility failed to monitor and intervene for the absence of bowel movements and complete daily skilled nursing assessments for a resident receiving skilled services. The resident was admitted with diagnoses including a stable burst fracture of the vertebrae, pulmonary fibrosis, and anxiety. A care plan indicated the resident was at risk for elimination problems, with a goal to maintain or improve elimination status. However, documentation showed the resident had a bowel movement on one day, with no further bowel movements recorded for the remainder of their stay. Despite the facility's practice of implementing interventions if a resident goes three days without a bowel movement, no such intervention was documented. Additionally, the facility did not complete daily skilled nursing assessments for the resident on three separate days. The Director of Nursing (DON) and RN confirmed that skilled assessments should be conducted daily for all skilled residents, yet there was no documentation of these assessments on the specified dates. The DON acknowledged the absence of a written policy for bowel movement monitoring and skilled nursing assessment frequency, but stated that the facility followed best standard practices, which were not adhered to in this case.
Failure to Complete Baseline Care Plans for New Residents
Penalty
Summary
The facility failed to complete baseline care plans for four of the seven sampled residents reviewed for baseline care plans. These residents included individuals with significant medical conditions such as congestive heart failure, non-Alzheimer dementia, hemiplegia, and diabetes mellitus with chronic kidney disease. The absence of baseline care plans was confirmed through record reviews and an interview with the Director of Nursing (DON), who stated that they were unable to locate the necessary documentation for these residents. This deficiency indicates a lapse in the facility's process for meeting the residents' immediate needs within 48 hours of admission.
Failure to Monitor Weights and Meal Intake
Penalty
Summary
The facility failed to ensure that weights were obtained and meal percentages were monitored as ordered by the physician for four residents. Resident #11, diagnosed with cerebral infarction and underweight, had a physician order for weekly weights and nutritional supplements, but weights were recorded monthly, and meal intake was inconsistently documented. Resident #56, with a femur fracture, also had a physician order for weekly weights, but meal intake was not consistently recorded. Resident #60, with diabetes mellitus and chronic kidney disease, had a similar order for weekly weights, but only one weight was recorded each month, and meal intake documentation was sparse. Resident #63, diagnosed with cerebral infarction, was to be weighed weekly for four weeks, but only two weights were recorded, showing a significant weight loss. The facility's policy required changes in diet, weight, and appetite to be reviewed during morning meetings, but this was not adhered to. Interviews with staff revealed that meal intake documentation was inconsistent due to a lack of supervision, and weight loss interventions were only implemented after a significant loss was noted. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the inconsistencies in documentation and monitoring, attributing them to inadequate supervision and failure to follow the facility's policy of weighing residents upon admission or the next day.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications according to accepted standards of practice. During an observation, an LPN discovered that a multi-use insulin pen labeled for one resident was mistakenly placed in a bag labeled for another resident. This error led to the need to order additional insulin for the affected resident. Additionally, the facility's medication storage practices were found to be inadequate, as a refrigerator intended for medication storage was not properly secured with a padlock, and an unlocked metal lock box inside contained 30 syringes of liquid Ativan labeled for a resident who had expired weeks prior. The Assistant Director of Nursing (ADON) acknowledged that they were unaware of the presence of the Ativan in the facility and that there was no narcotic count sheet associated with it. The ADON explained that medications from the primary pharmacy typically came with narcotic count sheets, but the Ativan was from a hospice pharmacy and lacked such documentation. This oversight meant that the medication was not routinely reconciled, and the nurses were unaware of its presence. The ADON also confirmed that all stored medications required proper labeling, highlighting a lapse in the facility's medication management practices.
Failure to Provide Beneficiary Notifications
Penalty
Summary
The facility failed to provide proper beneficiary notifications to two residents who were discharged from skilled services but remained in the facility as long-term care residents. Resident #54 was discharged from skilled services on September 29, 2024, and Resident #66 on August 28, 2024. Both residents had skilled days remaining, yet neither they nor their representatives were provided with an Advance Beneficiary Notice (ABN). The social services director acknowledged that the ABNs were not provided, mistakenly believing that the MDS coordinator had taken care of it. The administrator confirmed that the social services director had not been trained on beneficiary notifications.
Failure to Complete Quarterly Assessment for a Resident
Penalty
Summary
The facility failed to ensure that quarterly assessments were completed for a resident at least once every three months. Specifically, a resident with a diagnosis of hypertension had their last quarterly assessment completed on June 27, 2024, and an annual assessment on September 25, 2024. However, no subsequent quarterly assessment was documented after the annual assessment. On January 30, 2025, the MDS coordinator confirmed that the last assessment was the annual one from September 2024 and was unable to explain why a quarterly assessment was not completed in December 2024. The Director of Nursing acknowledged that a quarterly assessment should have been conducted in December for the resident.
Failure to Complete and Transmit Resident Assessments
Penalty
Summary
The facility failed to ensure timely encoding and transmission of assessments for two residents. Resident #70, diagnosed with hypertension, was discharged from the facility on 10/31/24, but a discharge return not anticipated assessment was not completed. The MDS coordinator was unaware of the reason for this omission. Resident #184, diagnosed with paraplegia, had discharge return anticipated assessments on 12/07/24 and 12/24/24, but no re-entry assessments were completed upon their return to the facility. The DON and MDS coordinator acknowledged that re-entry assessments should have been completed on 12/08/24 and 12/25/24, but the previous MDS coordinator had not been fulfilling this requirement.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a complete discharge summary for a resident who was discharged to home. The resident, who had a diagnosis of hypertension, was discharged on 10/31/24. The Interdisciplinary Discharge Summary form in the electronic clinical record was incomplete, with only the dietary and activities sections filled out, and lacked a recapitulation of the resident's stay. The Director of Nursing (DON) acknowledged that each department was responsible for completing their section of the discharge summary and admitted that the summaries were not being completed to include a recapitulation of the residents' stays.
Failure to Consistently Assess Dialysis Access Site Post-Dialysis
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis was properly assessed after each dialysis session. The facility's policy required that a community nurse complete a post-dialysis assessment and document it on the Dialysis Pre/Post Communication Report forms. However, the treatment records and communication forms for specific dates in December 2024 and January 2025 did not show that the resident's fistula was assessed after dialysis. This lack of documentation indicates that the required post-dialysis assessments were not consistently performed. The resident involved had end-stage renal disease and was scheduled to receive dialysis three times a week. Despite the facility's policy and the physician's order, the resident reported that their dialysis access site was not assessed every time they returned from dialysis. Interviews with facility staff, including an LPN and the DON, revealed that while assessments were supposed to be conducted and documented, staffing changes had led to inconsistencies in completing the dialysis communication forms. The DON acknowledged that the administrative staff monitored documentation weekly, but the post-dialysis assessments had not been consistently completed due to these staffing changes.
Failure to Conduct Monthly Medication Reviews and Address Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that medications were reviewed monthly by the consultant pharmacist and that pharmacy recommendations were addressed by the physician for a resident reviewed for unnecessary medications. The facility's policy required the consultant pharmacist to review the medication regimen and medical chart of each resident at least monthly, with recommendations to be acted upon within 30 calendar days or per facility-specific protocols. However, the clinical record and monthly medication regimen reviews did not show a medication regimen review by the consultant pharmacist for December 2024. A resident with a diagnosis of chronic pain was involved in this deficiency. The consultant pharmacist had made a recommendation on May 31, 2024, regarding the titration of gabapentin for the resident, suggesting a dose reduction. This recommendation was not addressed by the physician until January 29, 2025. The Director of Nursing (DON) stated they could not locate the medication regimen review for December 2024 and acknowledged that the pharmacist's recommendation from May 31, 2024, had not been previously addressed, indicating a lapse in the facility's medication review process.
Failure to Conduct Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were conducted as ordered by the physician for a resident with diabetes mellitus. The physician had ordered a complete blood count (CBC) to be performed every six months in March and September, and a hemoglobin A1C test every three months in March, June, September, and December. However, a review of the clinical records revealed that the CBC was not completed in September, and the hemoglobin A1C tests were not completed in June, September, or December. The Director of Nursing (DON) stated that the Assistant Director of Nursing (ADON) was responsible for ensuring that labs were completed as ordered, but the tests were not conducted because they were not entered into the lab company's ordering system.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain infection control and adhere to Enhanced Barrier Precautions (EBP) during the treatment of a pressure ulcer for one of the residents reviewed for wound care. The facility's policy, revised in April 2024, mandates the use of EBP, which includes donning gowns and gloves during high-contact care activities, especially for residents with wounds or indwelling medical devices. Despite this policy, the wound care nurse did not wear a gown while treating a resident with a stage 2 pressure ulcer, which was identified as requiring EBP according to the facility's policy. During the wound care procedure, the nurse only donned gloves and did not follow the EBP protocol of wearing a gown. The nurse and the Director of Nursing (DON) both misunderstood the policy, believing that EBP precautions were only necessary for more severe wounds or those with drainage or catheters. This misunderstanding led to the failure to implement the required infection control measures for the resident with a stage 2 pressure ulcer, as confirmed by the facility's policy and the statements from the Registered Nurse Consultant (RNC).
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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 Norman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Norman, Llc | 0.8 mi | ★★★★★ | 0 | 0 |
| Grace Skilled And Nursing Therapy Norman | 0.8 mi | ★★★★★ | 3 | 0 |
| 24th Place | 2 mi | ★★★★★ | 13 | 1 |
| Holiday Heights Healthcare | 3.5 mi | ★★★★★ | 0 | 0 |
| Noble Health Care Center | 8.3 mi | ★★★★★ | 2 | 0 |
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