Below 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 Memory Care Center At Emerald during CMS and state inspections, most recent first.
Failure to Protect Resident from Physical Abuse by Another Resident: A resident with severe cognitive impairment and dementia physically assaulted another severely cognitively impaired resident in a common area, grabbing the resident by the arms and throwing the resident to the floor. The injured resident was sent to the hospital and diagnosed with a closed displaced fx of the R femoral neck requiring surgical repair. The incident occurred while a CNA was assisting in another room and the day area was not covered as intended.
Failure to maintain a full-time DON: The facility did not have a full-time DON or an interim DON after the former DON resigned, and the administrator stated no one had accepted the DON responsibilities. The facility also failed to ensure RN coverage for the required hours during the review period, and the administrator reported being unable to locate a policy regarding DON employment.
Failure to timely report abuse allegations: The facility did not notify OSDH and law enforcement within 2 hours after abuse allegations became known for two residents. One resident reported sexual abuse to staff, and another resident was thrown to the ground by another resident; in both cases, the reports were sent later than required and law enforcement was contacted after the delay.
Drugs and biologicals were not kept at proper temperatures in the medication refrigerator. Surveyors found only 2025 temperature logs, with no 2026 log present. An ADON stated they had never checked or completed the refrigerator temperature log and did not know who was responsible, and the DON stated the task was a nursing responsibility but was unsure when it stopped being done or why. The DON also stated there was no policy for refrigerated medications.
Failure to document or offer flu and pneumococcal vaccines for two residents. One resident had severe cognitive impairment and another had intact cognition, but neither EMR showed evidence that the vaccines were offered or given. The ADON stated the immunization section was incomplete and that new admits were not offered the flu vaccine if they arrived after the annual influenza clinic, typically held in October.
The facility failed to ensure COVID-19 vaccination was offered and documented for two residents reviewed for immunizations. EMR review showed no documentation that either resident had received any immunizations, and the ADON stated there was no record that the residents had been offered or administered the COVID-19 vaccine. The facility policy required education before vaccination and documentation of vaccination status for new residents.
Unnecessary psychotropic medication orders were identified for a resident. The resident had Seroquel ordered for dementia and behaviors, and the MAR showed repeated doses were given. The resident also had an as-needed diazepam order for anxiety without a discontinue date, and the ADON stated the PRN order should have been limited to 14 days.
A resident with severe cognitive impairment, stroke, and dementia had repeated verbal and physical aggressive behaviors toward staff and other residents, including threats, lunging, and shoving another resident to the floor. Although the care plan addressed wandering and other behaviors, it did not include interventions for aggression toward others, and the MDS Coordinator acknowledged the care plan was not revised to reflect the resident’s new aggressive behaviors.
The facility failed to complete an annual competency review for one CNA sampled for review. Record review showed the 2025 competency for the CNA, hired in 2024, could not be provided. The administrator stated annual performance reviews were the DON's responsibility, but the facility was having difficulty keeping a DON and did not have a policy regarding competencies, though they knew annual competencies were required.
A facility failed to ensure a monthly pharmacy review was completed for a resident receiving multiple medications, including aspirin, Celexa, metoprolol, Remeron, Seroquel, apixaban, acetaminophen, and diazepam. The ADON reviewed the resident’s pharmacy consultant reports but could not find the monthly pharmacy review form, and the administrator stated nursing was responsible for ensuring the reviews were completed.
A resident reported to an LPN that they were involved in a romantic relationship with a CNA, that an unidentified LPN had sexually assaulted a resident, and that a CNA was living at the resident's home and receiving monthly payments. The LPN documented informing the ADON and administrator, but the administrator did not report the allegations, and the DON was unaware of them and did not investigate or report to state authorities.
A resident with severe cognitive impairment made multiple allegations of sexual abuse and misappropriation involving staff, which were documented in progress notes and reported to supervisory staff. However, the DON and administrator either did not review the notes or failed to initiate an investigation, and the alleged staff member continued working without suspension. The facility did not follow its policy to immediately investigate and protect residents from alleged perpetrators.
A resident with severe dementia was found unresponsive on a courtyard patio, suffering from heat exhaustion due to inadequate supervision. Staff interviews revealed that the courtyard doors were improperly propped open, allowing the resident unsupervised access, and the resident was not appropriately monitored.
The facility failed to maintain proper food service sanitation and storage requirements. Observations included a cook without a beard guard, multiple food items without date labels, and various areas with visible debris and dirt. Additionally, the dishwasher and three-compartment sink did not reach required temperatures for proper sanitization, and black mold was identified around the sink area.
The facility failed to ensure that the code status was correctly completed and that two residents were offered the choice to formulate advanced directives. One resident's POA incorrectly initialed both full code and DNR, and another resident had no advanced directive on file.
The facility failed to ensure wheelchairs were clean and maintained in good repair for two residents. Observations revealed torn armrests with yellow padding showing and dirty wheelchairs. The ADON confirmed the need for cleaning and repair, noting that torn armrests could not be properly disinfected.
The facility failed to implement its abuse policy by not reporting or investigating allegations of abuse and neglect for three residents and did not provide abuse training upon hire for seven employees.
The facility failed to develop care plans for a resident receiving oxygen therapy and another with a hand contracture. The care plans lacked documentation and interventions for both conditions, as confirmed by staff and observations.
The facility failed to provide sufficient staff for resident care. One resident with neurocognitive disorder was left without incontinent care for hours due to no CNAs being assigned to their hall. Another resident with dementia was not properly supervised during meals, leading to inadequate food intake. Additionally, the facility was without a licensed nurse for 3.5 hours, leaving residents without adequate supervision.
The facility failed to ensure that an LPN and three CNAs received required competency and skills checks, as revealed by a review of employee files and confirmed by the ADON. This lapse is contrary to the facility's policy, which mandates that staff must have the appropriate competencies to ensure resident safety and well-being.
The facility failed to ensure RN coverage for at least 8 consecutive hours daily, seven days a week, and did not have a full-time DON. Time punch records and interviews revealed inconsistent RN presence and a vacant DON position for two weeks, leading to the deficiency.
The facility failed to follow the planned lunch menu, resulting in five residents not receiving buttered egg noodles and one resident not getting their requested meal. Additionally, the dessert was not prepared on time.
A resident with acute respiratory failure and hypoxia had their oxygen tubing improperly stored, leading to cross-contamination risks. The tubing was found lying on the floor and hanging from the regulator, both discolored and dirty. The humidifier bottle was also out of water and stained. The ADON confirmed these deficiencies.
The facility failed to ensure that emergency call cords in the bathrooms were long enough to be reached by residents if they were lying on the floor in the shower. This deficiency was observed in two residents who were able to independently shower, posing a potential risk to their safety.
The facility failed to ensure a resident with dementia was treated with dignity during dining. A nurse left the resident with food on their plate to assist another resident, and the resident indicated they were still hungry. Another CNA resumed feeding the resident after being informed.
A facility failed to investigate a resident's alleged abuse and subsequent STI diagnosis. Despite the resident's cognitive impairment and statements suggesting possible sexual assault, no investigation was initiated. The facility did not comply with its own policy or regulatory requirements.
The facility failed to ensure accurate MDS assessments for a resident with limited range of motion. The resident's annual assessment documented no impairment, but observations and interviews confirmed the resident's hand was contracted. The ADON acknowledged the assessment was filled out incorrectly.
The facility failed to include a care plan regarding isolation for a resident admitted with dementia, brain degeneration, and anxiety disorder. Despite an infection note ordering isolation precautions, the care plan did not document these precautions. The MDS coordinator confirmed the omission.
The facility failed to complete and document neurological checks after a resident with severe cognitive impairment experienced two falls with head injuries. Despite initiating neuro monitoring, the facility was unable to locate the neuro sheets for both incidents.
A resident with acute respiratory failure was found using undated and outdated oxygen tubing, and a discolored nasal cannula. The humidifier bottle was also out of water and stained. The ADON and RN confirmed that the equipment should be changed weekly and dated, but this was not done, compromising the resident's respiratory care.
The facility failed to ensure antipsychotic medications were ordered with an appropriate diagnosis for a resident. The resident was prescribed aripiprazole for unspecified dementia, which the ADON confirmed was not an appropriate diagnosis for this medication.
The facility failed to explain the arbitration agreement in a manner that a resident's family member could understand, leading to the family member unknowingly waiving their right to litigation in court. The Social Services Director did not provide sufficient information about the agreement, including the 30-day rescission period.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse by another resident. The report states that the facility had a policy requiring residents not be subject to abuse by anyone, including other residents, and that staff should observe resident behavior and reactions to other residents, roommates, and tablemates. The administrator identified 58 residents in the facility, and the deficiency involved 1 resident out of 3 sampled residents reviewed for abuse. Resident #24 had severe cognitive impairment, with a BIMS score of 6, and diagnoses including stroke and dementia; the assessment also noted verbal behaviors toward others in the prior seven-day look-back period. Resident #64 also had severe cognitive impairment, with a BIMS score of 00 and a diagnosis of dementia, and no physical or verbal behaviors toward others were noted on assessment. On 05/16/26, CNA #1 stated they heard Resident #64 make a noise while assisting in another room, then entered the common area and observed Resident #24 grab Resident #64 by the arms and throw Resident #64 to the ground. Facility documentation showed Resident #64 was shoved to the floor, was wincing from pain, was sent to an acute care hospital, and was later diagnosed with a closed displaced fracture of the right femoral neck requiring surgical repair. The administrator stated CNA #1 should not have left the day area to work alone in a resident room and should have asked someone to watch the day area, noting the facility had a system for coverage that was not followed in this instance.
Failure to Maintain a Full-Time DON
Penalty
Summary
The facility failed to ensure it had a full-time DON and a registered nurse on duty 8 hours a day for 8 of 30 dates reviewed related to the employment of a DON. The administrator identified that 58 residents resided in the facility. An email from the former DON to the administrator, dated 05/25/26 at 4:11 p.m., showed the DON resigned effective that date. On 05/29/26, the administrator stated the facility did not have a full-time DON, did not have anyone who had accepted the responsibilities of the DON position, and had not been able to find a full-time or interim DON since the resignation. On 06/02/26, the administrator again stated they had not found anyone to assume the duties of the DON and were unable to locate a policy regarding the employment of a DON.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure the OSDH and a local law enforcement agency were notified of allegations of abuse within two hours of the allegations becoming known to the facility for 2 of 3 sampled residents reviewed for abuse. The administrator identified 58 residents resided in the facility. A facility policy titled Abuse, Neglect and Exploitation, dated 01/2024, stated alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but no later than 2 hours after the allegation is made, to the administrator and other official agencies in accordance with State law. For one resident, an allegation of sexual abuse was reported by the resident to staff, but the incident report was faxed to the OSDH the next day and law enforcement was contacted later that same day. For another resident, the resident was thrown to the ground by another resident, but the incident report was faxed to the OSDH the following day and law enforcement was contacted later that day. On interview, the administrator stated they were the facility's abuse coordinator, but the incident reports were written and sent to the OSDH by other staff members, and the facility had not sent the reports to OSDH and law enforcement within two hours in the two instances.
Medication Refrigerator Temperature Logs Not Maintained
Penalty
Summary
Drugs and biologicals were not kept at proper temperatures in 1 of 1 medication refrigerator. On observation, the only temperature logs available were from 2025, and no temperature log was present for 2026. The ADON stated they had never completed the temperature log or checked the refrigerator temperature and did not know who was responsible for the task. The administrator later stated that checking the medication refrigerator temperature and maintaining the logs was a nursing task, but they were ultimately responsible for ensuring it was completed, and they were uncertain when the task stopped being done or why. The administrator also stated there was no policy for medications requiring refrigeration.
Failure to Document or Offer Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure influenza and pneumococcal vaccinations were offered or documented for 2 of 5 sampled residents reviewed for immunizations. A policy titled Infection Control Immunizations, dated 03/20/24, required that residents or legal representatives receive education about vaccination benefits and side effects before vaccination, that this education be documented in the medical record, and that all new residents be assessed for current vaccination status upon admission. A quarterly MDS assessment dated 04/22/26 showed one resident was admitted with a BIMS score of 4, indicating severe cognitive impairment, and the EMR contained no documentation that the influenza vaccine or pneumococcal vaccine had been offered or given. A quarterly MDS assessment dated 05/11/26 showed another resident was admitted with a BIMS score of 14, indicating intact cognition, and the EMR also contained no documentation that the influenza vaccine or pneumococcal vaccine had been offered or given. The ADON stated on 05/28/26 that the immunization section for both residents was not completed and there was no documentation showing whether either vaccine had been offered, and further stated that new admits were not offered influenza vaccine if they arrived after the facility had completed its annual influenza clinic, which was typically held in October.
Failure to Document and Provide COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure the COVID-19 vaccine was provided for 2 of 5 sampled residents reviewed for immunizations, identified as Res #8 and Res #10. Record review showed no documentation in either resident's EMR that any immunizations had been provided, including the COVID-19 vaccine. The facility's Infection Control Immunizations policy stated that prior to receiving vaccinations, the resident or legal representative would be provided information and education regarding the benefits and potential side effects of the vaccinations, that this education would be documented in the resident's medical record, and that all new residents would be assessed for current vaccination status upon admission. The ADON stated on interview that the EMRs for Res #8 and Res #10 had been reviewed and there was no documentation that the residents had been offered or administered the COVID-19 vaccination.
Unnecessary Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure an antipsychotic medication was not prescribed for the diagnosis of dementia and failed to ensure an as-needed anxiety medication order had a 14-day limit for one resident. Record review showed the resident had an order for Seroquel 50 mg at bedtime for dementia and behaviors, and the medication administration record showed the resident received 24 doses during the month reviewed. The ADON stated they were familiar with antipsychotic medications but did not know whether they were approved for the treatment of dementia, and stated the resident was prescribed Seroquel because they kicked and squeezed staff hands. The resident also had an order for diazepam 5 mg/ml oral concentrate, 0.5 ml by mouth every four hours as needed for anxiety, and the order did not include a discontinue date. A pharmacy consult report documented that the physician was informed that as-needed psychotropic medication orders required a 14-day limit unless a written rationale for a longer limit was provided, but the report did not show a written response from the physician. The ADON stated the as-needed diazepam order should have been limited to 14 days, and the administrator stated the nursing department needed to review medication orders more closely to find these types of issues.
Failure to Revise Care Plan for Resident With Repeated Aggressive Behaviors
Penalty
Summary
The facility failed to revise the care plan for a resident with severe cognitive impairment and a history of stroke and dementia after multiple incidents of aggressive behavior toward others. The resident’s care plan, dated 03/31/26, addressed behaviors and wandering, including taking food from other residents’ plates, reaching over the counter, and not caring to be redirected, but it did not include interventions related to aggression toward others. The resident’s admission assessment showed a BIMS score of 6 and documented verbal behaviors toward others during the seven-day look-back period. The record showed repeated aggressive events after admission, including lunging at staff when prevented from eating from another resident’s plate, threatening to physically assault a CNA when a cupcake was removed, moving within inches of a staff member’s face and asking if they wanted to fight, lunging at another resident, threatening to physically assault that resident, and aggressively shoving another resident to the floor. The MDS Coordinator stated the care plan should have been revised when the resident’s aggressive behaviors occurred and acknowledged the behaviors had happened but were not entered into the care plan. CNA and CMA staff stated they had observed and reported the resident’s verbal threats and abusive behavior to nursing staff, and the administrator stated new interventions should have been created regarding the resident’s aggressive behaviors.
Failure to Complete Annual CNA Competency Review
Penalty
Summary
The facility failed to complete an annual performance review for CNA #3, one of two CNAs sampled for performance reviews. Record review showed the facility could not provide the 2025 annual competency for CNA #3, who was hired on 01/28/24 according to the employee application. The current staff roster identified 13 CNAs employed. During interview on 06/02/26 at 3:26 p.m., the administrator stated that completing annual performance reviews was the DON's responsibility, but the facility was having difficulty keeping a DON. The administrator also stated the facility did not have a policy regarding competencies, but knew the regulations required annual competencies to be completed.
Missing Monthly Pharmacy Review
Penalty
Summary
The facility failed to ensure a monthly pharmacy review was completed for one resident reviewed for unnecessary medications. The resident’s MAR for 01/01/26 through 01/31/26 showed 12 prescribed medications, including aspirin, Celexa, metoprolol, Remeron, Seroquel, apixaban, acetaminophen, and diazepam. During record review and interview on 06/01/26, the ADON reviewed the resident’s pharmacy consultant reports and was unable to locate the January 2026 monthly pharmacy review form. On 06/02/26, the administrator stated the nursing department was responsible for ensuring the pharmacy reviews were completed.
Failure to Report and Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property to the Oklahoma State Department of Health as required by both facility policy and state law. According to a progress note, a resident reported to an LPN that they were involved in a romantic relationship with a CNA, that an unidentified LPN had sexually assaulted a resident on two occasions, and that an unidentified CNA was living at the resident's home and receiving monthly payments from the resident. The LPN documented that these allegations were communicated to the Assistant Director of Nursing (ADON) and the administrator. Upon interview, the administrator confirmed awareness of the allegations but stated they had not reported the incident or participated in the investigation, as those responsibilities were assigned to the Director of Nursing (DON). However, the DON stated she had not seen the progress note or been informed of the allegations prior to being shown the note by the surveyor, and therefore had not reported the allegations to the state or initiated an investigation. This sequence of events resulted in the facility's failure to report and investigate serious allegations as required.
Failure to Investigate and Respond to Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and misappropriation involving a resident with severe cognitive impairment, as indicated by a BIMS score of 03. Progress notes documented that the resident reported having a romantic relationship with a CNA, alleged sexual assault by an unidentified LPN, and claimed a CNA was living at their home and receiving monthly payments. These allegations were communicated to the ADON and administrator, but there was no evidence of an immediate or comprehensive investigation. Additionally, another progress note documented an allegation of stolen credit cards, but this was not reported to administration or investigated. Interviews revealed that the DON and administrator were either unaware of or did not act upon the documented allegations. The DON stated they had not seen the relevant progress notes or conducted any investigation, and the administrator indicated they had delegated the responsibility but did not follow up. The alleged perpetrator, CNA, was not suspended and continued working scheduled shifts. Staff interviews confirmed that allegations were either not communicated to the appropriate personnel or not acted upon, resulting in a lack of protective measures for the resident and failure to follow facility policy requiring immediate investigation of abuse, neglect, or exploitation.
Resident Neglect Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by an incident involving a resident with severe unspecified dementia and anxiety. The resident was found unresponsive on a concrete patio in the courtyard, having suffered from heat exhaustion and volume depletion. The resident was discovered by a CMA and was unresponsive to a sternal rub, prompting staff to call 911. The hospital discharge paperwork confirmed the diagnoses related to the incident. Interviews with various staff members, including CNAs, LPNs, and the ADON, revealed that the courtyard doors should have been locked, and residents should not have been outside without supervision. It was noted that the door between the courtyard and the 600-hall was propped open with a chair, allowing the resident to access the area unsupervised. The ADON admitted that the resident was not being adequately supervised, and the Administrator confirmed the lack of appropriate supervision at the time of the incident.
Failure to Maintain Proper Food Service Sanitation and Storage
Penalty
Summary
The facility failed to ensure proper food service sanitation, cleaning, and storage requirements were followed. During a tour of the kitchen, several deficiencies were observed, including a cook not wearing a beard guard, multiple food items without date labels, and various areas with visible debris and dirt. Specifically, opened bags of cheese, boiled eggs, butter, milk, liquid eggs, bacon, and ranch dressing were found without date labels. Additionally, a red/pink drinking cup was found on a bottom shelf next to plastic ware, and multiple shelves and toasters were covered with black, brown, and white debris. The cook admitted to not being sure about the hair net policy and acknowledged the lack of cleanliness and proper labeling in the kitchen. The kitchen was reportedly swept and mopped every night, and shelves were cleaned every Wednesday, but these measures were insufficient to maintain proper sanitation standards. Further observations revealed black substance splattered on the wall around the sink area, which was identified as black mold by a dietary aide. The low-temperature dishwasher never reached above 100 degrees, and the three-compartment sink sanitizer compartment never reached above 10 ppm. Despite these issues, the dishwasher continued to be used, and the three-compartment sink was set up for usage after lunch. The hot water from the faucet was only 88 degrees when the dishwasher was running, and the sanitization level remained too low at 10 ppm. The blender used for preparing mechanical soft and puree food was washed in the dishwasher that had not reached the required temperature. The maintenance supervisor was observed in the kitchen dishwasher area during the follow-up observation.
Failure to Ensure Correct Code Status and Offer Advanced Directives
Penalty
Summary
The facility failed to ensure that the resident's representative completed the resident's code status correctly and offered the choice to formulate an advanced directive for two residents. For Resident #6, the Power of Attorney (POA) incorrectly initialed both full code and Do Not Resuscitate (DNR) on the code status document. Additionally, there was no documentation that Resident #6 had been offered or declined the opportunity to formulate an advanced directive. The office assistant confirmed that they did not ask any residents with dementia diagnoses if they wanted information to formulate an advanced directive. For Resident #48, who was admitted with diagnoses including Huntington's disease and unspecified dementia, there was no advanced directive on file. The Business Office Manager (BOM) confirmed that Resident #48 had not been offered the choice to formulate advanced directives. This indicates a failure in the facility's admission process to review and incorporate the resident's wishes regarding advanced care planning into their plan of care.
Failure to Maintain Clean and Repaired Wheelchairs
Penalty
Summary
The facility failed to ensure wheelchairs were clean and maintained in good repair for two residents. Resident #1's quarterly assessment documented that they ambulated with a manual wheelchair and walker. On observation, the wheelchair armrests were torn with yellow padding showing, and the wheelchair was dirty. Similarly, Resident #25's significant change assessment documented that they ambulated with a manual wheelchair. On observation, the wheelchair armrests were also torn with yellow padding showing, and the wheelchair was dirty. The ADON confirmed that the CNAs were responsible for notifying the nurse of the need for wheelchair maintenance, and the nurse would then notify maintenance. The ADON acknowledged that the wheelchairs needed cleaning and the armrests required repair, noting that torn armrests could not be properly disinfected or cleaned.
Failure to Implement Abuse Policy and Provide Training
Penalty
Summary
The facility failed to implement its abuse policy in several instances. For Resident #6, who had dementia and late-onset Alzheimer's Disease, a grievance was logged stating that night shift staff tried to smother the resident and pulled their call light out of reach. Despite this being considered an allegation of abuse by the SSD and the administrator, no investigation was conducted, nor was the incident reported to the OSDH. Similarly, for Resident #9, who had frontotemporal neurocognitive disorder and required substantial assistance with daily activities, a grievance was logged indicating neglect due to the absence of a CNA to provide care, resulting in the resident being found with dried urine. This incident was also not reported to the OSDH, and no investigation was conducted despite the SSD and administrator acknowledging it as an allegation of neglect. Additionally, Resident #41, who had Alzheimer's Disease and bipolar disorder, was involved in an incident where another resident pushed them, causing a fall and a minor injury. This incident was documented but not reported to the state. Furthermore, the facility failed to provide abuse training upon hire for seven employees, as their personnel files lacked documentation of such training. The HR department confirmed the absence of abuse training records for these employees.
Failure to Develop Care Plans for Oxygen Therapy and Contracture
Penalty
Summary
The facility failed to develop a care plan for oxygen therapy for one resident who received oxygen therapy and for another resident with limited range of motion and contracture. Resident #6, diagnosed with acute respiratory failure with hypoxia, had physician's orders for continuous oxygen therapy via nasal cannula. However, the care plan did not document the use of oxygen therapy, the frequency of changing the nasal cannula, oxygen safety, or any interventions. Observations confirmed the presence of oxygen equipment in the resident's room, and the MDS coordinator acknowledged the omission in the care plan. Resident #20's care plan did not document the resident's limited range of motion or contracture in the left hand, nor did it include interventions to prevent the contracture from worsening. The resident's family member and a CNA confirmed the contracture, and observations noted the absence of a splint or brace. The ADON also confirmed the lack of documentation and interventions in the care plan for the resident's contracted hand.
Staffing Deficiencies in Resident Care and Supervision
Penalty
Summary
The facility failed to ensure sufficient staff was available to provide necessary care for residents. Resident #9, diagnosed with frontotemporal neurocognitive disorder, required substantial assistance with toileting and was frequently incontinent. On 01/04/24, there were no CNAs assigned to the Burgundy hall during the night shift, resulting in Resident #9 not receiving incontinent care until 5:00 a.m., as documented in a grievance log. The ADON confirmed that the schedule did not reflect a staff member assigned to the Burgundy hall and that the CNA from the Green hall should have assisted but refused to do so. This led to Resident #9 being left in soiled conditions for an extended period. Resident #46, diagnosed with extrapyramidal and movement disorder, anxiety, and dementia, required supervision and cuing during meals. On 05/09/24, during breakfast, staff members were observed assisting other residents, but no one was seated with Resident #46 to ensure they stayed in the dining area and ate their meal. The resident was seen wandering and only ate sporadically. The MDS coordinator and ADON confirmed that staff should have been seated next to Resident #46 to provide the necessary supervision. Additionally, on 05/12/24, the facility was without a licensed nurse for 3.5 hours due to a call-in, leaving residents without adequate supervision and care during that period. A family member of another resident reported that their call light was not answered for over 40 minutes, indicating insufficient staffing levels.
Failure to Conduct Competency and Skills Checks for Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses and certified nurse aides received competency and skills checks, as required by their policy. The review of employee files revealed that four staff members, including one LPN and three CNAs, did not have documented competency or skills checks. Specifically, the LPN was hired in December, and the three CNAs were hired between September and November, yet none had completed the necessary evaluations to confirm their competencies in caring for residents as per the facility's policy. During an interview, the Assistant Director of Nursing (ADON) confirmed the absence of skills check-offs for the identified staff members and acknowledged that annual skills check-offs should be conducted. This deficiency indicates a lapse in the facility's adherence to its own policy, which mandates that staff must have the appropriate competencies and skill sets to ensure resident safety and well-being, as identified through resident assessments and care plans.
Failure to Ensure RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to ensure the services of a registered nurse (RN) were available for at least 8 consecutive hours daily, seven days a week, and did not have a full-time Director of Nursing (DON). The review of time punches from April 1st, 2024 through May 5th, 2024 revealed that RN #1 and RN #2 did not provide consistent daily coverage, with several days lacking any RN presence. Additionally, the previous DON had taken paid time off (PTO) for multiple days, and the position had been vacant for two weeks at the time of the survey. The facility had been without a designated DON for 37 days and lacked RN coverage for 14 days within the specified period. Interviews with the Administrator and Assistant Director of Nursing (ADON) confirmed the absence of a full-time DON and the inconsistent RN coverage. The Administrator acknowledged the vacancy in the DON position and the insufficient RN staffing, stating that they only had one part-time and one PRN RN. The ADON verified the lack of daily RN coverage and the absence of a full-time DON, further confirming the findings from the time punch records. The facility's failure to maintain the required RN coverage and a full-time DON led to the identified deficiency.
Failure to Follow Menus and Meet Nutritional Needs
Penalty
Summary
The facility failed to ensure menus were followed for one meal preparation and service observed. The policy required that menus meet residents' nutritional, religious, cultural, and ethnic needs and be followed. On the observed date, the lunch menu was supposed to include chicken paprikash, buttered egg noodles, squash medley, melon cubes, and a beverage. However, the actual meal served did not include the buttered egg noodles for five residents, as the remaining noodles were stuck to the pan. Additionally, the dessert was not prepared on time, and one resident did not receive their requested meal of sandwich meat and cheese roll-up because Cook #1 stated they did not have time to make it. This resulted in deviations from the planned menu and unmet dietary needs for the residents.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to ensure proper storage of oxygen tubing to prevent cross-contamination for a resident diagnosed with acute respiratory failure with hypoxia. The resident's monthly physician's orders included continuous oxygen therapy via nasal cannula. On multiple occasions, the resident's oxygen tubing was observed lying on the floor and hanging from the regulator, both of which were discolored and dirty. Additionally, the humidifier bottle attached to the oxygen concentrator was found to be out of water and had visible water stains. The Assistant Director of Nursing (ADON) confirmed that the nasal cannula was dirty and improperly stored, and that the humidifier bottle needed to be changed.
Inaccessible Emergency Call Cords in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that emergency call cords in the bathrooms were long enough to be reached by residents if they were lying on the floor in the shower. This deficiency was observed in two residents who were able to independently shower. For Resident #44, the emergency call cord was located next to the toilet and not within reach of the shower. The Assistant Director of Nursing (ADON) confirmed that Resident #44 would not be able to reach the call light if they fell in the shower. Resident #44 was aware of the purpose of the call cord and had the cognitive ability to use it, but the placement rendered it ineffective in the shower area. Similarly, for Resident #56, the emergency call cord was also located next to the toilet and not within reach of the shower. The Certified Nursing Assistant (CNA) stated that Resident #56 preferred to shower independently without supervision, and the ADON confirmed that staff should stay in the resident's room to provide privacy while the resident showered. However, the placement of the call cord did not allow Resident #56 to reach it in case of an emergency while in the shower. The ADON identified 12 residents in total who had the cognitive ability to utilize the call light, indicating a broader issue with the placement of emergency call cords in the facility. The observations and interviews revealed that the facility did not ensure the emergency call cords were accessible to residents in the shower, posing a potential risk to their safety. The deficiency was identified through direct observation and staff interviews, highlighting a failure in the facility's emergency preparedness for residents who shower independently.
Failure to Ensure Resident Dignity During Dining
Penalty
Summary
The facility failed to ensure a resident was treated with dignity during dining. Resident #20, who had a diagnosis of dementia and was dependent on staff for eating, was observed during a meal where RN #1 left the resident with food on their plate to assist another resident across the room. During this time, another resident encouraged Resident #20 to eat, but no staff were present to assist. When asked if they were hungry, Resident #20 nodded yes, indicating they still wanted to eat. CNA #7, upon being informed of this, resumed feeding Resident #20, who then ate the food provided by the CNA. The ADON acknowledged that staff should not have stopped feeding one resident to assist another across the room. The facility's policy on Activities of Daily Living (ADLs) states that residents who are unable to carry out ADLs will receive the necessary services to maintain good nutrition. The ADON stated that during meal times, the nurse, CMA, CNA, and float CNA should be present to assist residents with eating, indicating a failure to adhere to this policy during the observed meal times.
Failure to Investigate Alleged Abuse and STI
Penalty
Summary
The facility failed to ensure an investigation was initiated for a resident who was suspected of being abused. The resident, who had moderately impaired cognition due to dementia, was found to have a small amount of blood in the rectal-vaginal area. Despite the resident's statement that 'the boys touched me' and the nurse practitioner's concern about possible sexual assault, the facility did not initiate an investigation as required by their Abuse, Neglect, and Exploitation policy. The resident was transported to the hospital, where a small external labial laceration was noted, but no active bleeding was present at the time of examination. Subsequently, the resident tested positive for Chlamydia, a sexually transmitted infection (STI). The nurse practitioner expressed concern that the resident, who was not known to be sexually active, could have been manipulated by someone. Despite this, the facility did not conduct an investigation into the source of the STI. The Assistant Director of Nursing (ADON) and the Administrator both confirmed that no investigation was conducted for the recent STI or the previous incident of bleeding. The Administrator stated that it would be difficult for someone to assault the resident without being noticed, given the hall's layout and staffing. However, they acknowledged that male employees worked at night and could be alone on the hall. Despite these circumstances, the facility did not take steps to test other residents for potential infection or to investigate the source of the STI, thereby failing to comply with their own policy and regulatory requirements.
Inaccurate MDS Assessment for Limited Range of Motion
Penalty
Summary
The facility failed to ensure that MDS assessments were accurate for a resident reviewed for limited range of motion. Specifically, Resident #20's annual assessment documented no impairment in the range of motion for the shoulder, elbow, wrist, or hand. However, observations and interviews revealed that the resident's left hand was contracted. On multiple occasions, the resident's family member, a CNA, and the ADON confirmed the contracture. The ADON reviewed the MDS assessment and acknowledged that it was filled out incorrectly, documenting no impairment in the upper extremities despite the resident's hand being contracted.
Failure to Include Isolation in Care Plan
Penalty
Summary
The facility failed to include a care plan regarding isolation for one of the 19 sampled residents reviewed for care planning. The resident was admitted with diagnoses including unspecified dementia, senile degeneration of the brain, and anxiety disorder. An infection note documented that a nurse practitioner ordered isolation precautions until the completion of antibiotic treatment. However, there was no documentation on the care plan regarding isolation precautions. The MDS coordinator confirmed that isolation was not included in the resident's care plan.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure neurological checks were completed after a fall with head injury for one of the sampled residents. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's Disease and bipolar disorder, experienced two incidents. In the first incident, the resident was pushed by another resident, resulting in a fall and a laceration on the nose. Neuro checks were initiated and found to be within normal limits, but no neuro sheets were located in the resident's chart for this incident. In the second incident, the resident was found lying on the concrete patio with a laceration above the right eye and significant bleeding. Neuro monitoring was initiated, and the resident was sent to the hospital for further evaluation. However, the facility was unable to locate neuro sheets for this incident as well. The Assistant Director of Nursing (ADON) confirmed that neuro checks should have been started for both incidents but were not documented properly.
Failure to Adhere to Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure that oxygen tubing was labeled, dated, and changed per facility policy for a resident receiving oxygen therapy. The resident had a diagnosis of acute respiratory failure with hypoxia and required continuous oxygen via nasal cannula. During observations, it was noted that the oxygen tubing connected to the oxygen concentrator was not dated, and the nasal cannula connected to the portable oxygen tank was dated over a month prior. Additionally, the nasal cannula was found to be discolored and the humidifier bottle was out of water and stained. The ADON confirmed that the tubing and humidifier bottle should be changed weekly and dated, and that the humidifier bottle should not run out of water. The nurse responsible for the resident's care was unaware of these requirements and failed to adhere to the facility's policy. The ADON and RN acknowledged the deficiencies upon review of the observations and photographs. The ADON stated that it was the nurse's responsibility to change the tubing and humidifier bottle and ensure they were properly dated and maintained. The failure to follow the facility's policy for oxygen therapy resulted in the resident using outdated and potentially contaminated equipment, which could compromise the resident's respiratory care and overall health.
Inappropriate Antipsychotic Medication Prescription
Penalty
Summary
The facility failed to ensure antipsychotic medications were ordered with an appropriate diagnosis for one of five sampled residents reviewed for unnecessary medications. Resident #5 was admitted with diagnoses including unspecified dementia and general anxiety disorder. A physician's order dated 09/20/22 documented aripiprazole 5 mg daily for unspecified dementia with behavioral disturbance. On 05/14/24, the ADON stated that schizophrenia, bipolar disorder, and depression were appropriate diagnoses for aripiprazole, but dementia was not. This indicates that the medication was prescribed without an appropriate diagnosis, contrary to regulatory requirements for psychotropic medications.
Failure to Adequately Explain Arbitration Agreement
Penalty
Summary
The facility failed to explain the arbitration agreement in a manner that the resident representative could understand. Specifically, a family member of a resident signed a Voluntary Arbitration Agreement without fully understanding its implications. The family member later stated that they did not realize they were giving up their right to litigation in court and were not informed that they could withdraw from the agreement within 30 days. The family member mentioned that the paperwork was presented quickly and under stressful conditions, which contributed to their lack of understanding. Further interviews revealed that the Social Services Director (SSD) did not adequately explain the arbitration agreement to residents or their representatives. The SSD admitted to keeping explanations short and simple, allowing the families to read the paperwork and ask questions but failing to inform them about the 30-day rescission period and the waiver of the right to go to court. The administrator acknowledged that the facility should consider the stress families are under when signing admission paperwork.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 126 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Claremore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Care Center Claremore | 0.1 mi | ★★★★★ | 9 | 0 |
| Claremore Skilled Nursing And Therapy | 1.6 mi | ★★★★★ | 5 | 0 |
| Rolling Hills Care Center | 12.5 mi | ★★★★★ | 3 | 0 |
| Baptist Village Of Owasso | 13 mi | ★★★★★ | 0 | 0 |
| North County Center For Nursing And Rehabilitation | 13.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.