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 Montevista Rehabilitation And Skilled Care during CMS and state inspections, most recent first.
A facility failed to verify and clarify physician orders for a resident's cholecystostomy drain, leading to improper management of the drain. Additionally, the facility did not transcribe and administer medications as ordered, including loratadine, magnesium glycinate, vitamin C, garlic, and zinc. The lack of a specific policy for drain management and failure to verify physician orders contributed to these deficiencies.
A facility failed to implement a baseline care plan within 48 hours for a resident with an IR drain, as required by policy. The resident, admitted with serious health conditions, did not have the IR drain included in the baseline care plan, which was completed nine days late. The DON confirmed the omission, and the administrator admitted the policy was not followed.
A facility failed to document a skin assessment for a resident with a physician-ordered wound treatment. The resident, with a history of diabetes and other conditions, was admitted with red buttocks and developed an open area. An LPN received a new order but did not document the wound's description in the eMAR. The resident left the facility before a scheduled wound care appointment, with the LPN noting worsening skin condition.
A facility failed to implement a specific policy and ensure proper training for nursing staff regarding cholecystostomy drain care for a resident with such a drain. The existing policy did not address this type of drain, leading to inconsistent practices among LPNs, who were unfamiliar with the specific care requirements. The resident had a cholecystostomy drain due to septic shock and gastrointestinal cancer, but the eTAR lacked instructions to measure output, and the LPNs had not received training on this type of drain.
A facility failed to notify a resident's representative of changes in the resident's skin condition, as required by their Change of Condition policy. The resident, with multiple diagnoses, developed a pressure ulcer, and a new physician order was issued for treatment. However, the LPN did not contact the representative, and the name of the person contacted was not charted, contrary to facility policy. The DON confirmed the need for accurate contact information in the eMAR.
The facility failed to update care plans with smoking interventions for two residents. One resident with cognitive impairment was observed smoking unsupervised, contrary to facility policy. Another resident, requiring staff assistance to access the smoking area, had no smoking interventions in their care plan. The DON acknowledged the oversight in care plan updates.
A resident was observed smoking without supervision in an enclosed courtyard, contrary to the facility's smoking policy requiring supervision for safety. The resident's care plan indicated a risk for injury and specified smoking only in designated areas with supervision. Despite this, the resident smoked outside designated times, as they admitted to saving a cigarette for unsupervised smoking. The administrator noted the resident's occasional noncompliance with the smoking schedule.
A facility failed to investigate and report an abuse allegation involving a resident on hospice services. Multiple staff members were aware of complaints against a CNA for rough treatment, but the administration did not act on these reports. The issue was only addressed after a complaint survey highlighted the potential abuse, leading to the CNA's suspension and an investigation.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, seven days a week, due to staffing shortages. The deficiency was noted during April and May 2024, with missing RN coverage on weekends. The administrator confirmed the hiring of the DON in June 2024 and the ADON in February 2024, highlighting staffing challenges during the period.
The facility failed to ensure proper food handling and staff hygiene, as observed during a kitchen tour. A staff member prepared a meal without a beard guard, violating the facility's policy. Additionally, during lunch preparation, staff used gloved hands instead of tongs to handle food, contrary to the facility's guidelines. The dietary supervisor acknowledged these lapses.
A resident with multiple health conditions was discharged without a complete discharge summary, lacking essential details such as a recapitulation of their stay and medication reconciliation. The resident, who was cognitively intact, was mistakenly picked up by a contact who believed they were discharged after signing a NOMNC. The responsible nurse failed to document the discharge, and subsequent attempts to contact the resident were unsuccessful.
A resident with dementia and other conditions eloped from the facility due to inadequate supervision and an unlocked front door. Despite being identified as a moderate risk for elopement, the resident was able to leave the premises and was found at a nearby dealership parking lot, requiring medical care.
A resident with a traumatic brain injury and a pureed diet order was hospitalized for aspiration pneumonia after being fed non-pureed food. The facility failed to ensure the resident received the correct diet, leading to respiratory distress and hospitalization. Staff interviews revealed previous instances of incorrect diets being provided, but these were not properly reported or addressed.
Failure to Verify Physician Orders and Administer Medications
Penalty
Summary
The facility failed to verify and obtain clarification from the physician regarding the frequency of flushing a cholecystostomy drain and recording its output for a resident. The resident's history and physical (H&P) indicated the need for the drain to be flushed twice daily, but the physician order packet only mentioned a daily flush without specifying the frequency. The Assistant Director of Nursing (ADON) admitted to not seeing the resident's drain and relied on the H&P for instructions, which were not part of the official physician orders. The ADON did not document any communication with the physician for clarification, and the facility lacked a specific policy for managing cholecystostomy drains. Additionally, the facility failed to administer medications as ordered by the physician for the same resident. The physician order packet included medications such as loratadine, magnesium glycinate, vitamin C, garlic, and zinc, which were not transcribed upon admission. The ADON and RN #1 confirmed that these medications were omitted from the electronic medication administration record (eMAR). The facility policy required another nurse to verify the physician orders, but this step was not completed, leading to the oversight. The facility's lack of a specific policy for cholecystostomy drains and failure to ensure proper transcription and verification of physician orders contributed to the deficiencies. The ADON and nursing staff did not adequately communicate or document the necessary steps to ensure the resident received appropriate care, resulting in a failure to follow physician orders for both the drain management and medication administration.
Failure to Implement Timely Baseline Care Plan for Resident with IR Drain
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for a resident with an IR drain, as required by their policy. The resident, who was admitted with diagnoses including intrahepatic bile duct carcinoma, perforation of gallbladder in cholecystitis, and acute kidney failure, did not have the IR drain included in the baseline care plan. The admission assessment noted the presence of an IR drain, but the baseline care plan completed nine days after admission did not list it under physician orders or treatments. The Director of Nursing confirmed the omission, and the administrator acknowledged that the facility policy was not followed, as the baseline care plan was completed late by an LPN.
Failure to Document Skin Assessment for Resident with Wound
Penalty
Summary
The facility failed to document a skin assessment for a resident who was reviewed for physician-ordered wound treatments. The resident had a medical history that included type 2 diabetes mellitus, intrahepatic bile duct carcinoma, and a perforation of the gallbladder. Upon admission, the resident's skin was noted to be intact with a surgical incision on the right upper abdomen. A subsequent skin assessment indicated redness on the buttocks, which was initially blanchable. However, a later assessment showed no surgical wound or rash/redness, despite a physician's order to treat a pressure ulcer in the buttocks/coccyx area. The Licensed Practical Nurse (LPN) involved reported that the resident was admitted with red buttocks and was developing an open area. The LPN received a new order from the physician but did not perform a skin assessment or document the wound's description in the electronic Medication Administration Record (eMAR). The resident was scheduled to be seen by a wound care doctor, but left the facility against medical advice before the appointment. The LPN noted that the left side of the resident's buttocks was redder, non-blanchable, and had a purple-reddish color with flaking skin, which raised concerns.
Lack of Policy and Training for Cholecystostomy Drain Care
Penalty
Summary
The facility failed to develop and implement a specific policy for cholecystostomy drain care for a resident with such a drain, and did not ensure that the nursing staff were properly trained and competent in managing this type of drain. The report highlights that the facility's existing policy, which was a performance checklist for managing wound drainage, did not specifically address cholecystostomy drains. This lack of a specific policy led to confusion and inconsistent practices among the nursing staff, as evidenced by interviews with three LPNs who were involved in the care of the resident with the cholecystostomy drain. The resident in question had a cholecystostomy drain as part of their treatment for septic shock and gastrointestinal cancer. The physician's order required the drain to be flushed twice daily with normal saline and to keep a daily record of output. However, the eTAR did not include instructions to measure the output, and the LPNs involved were not familiar with the specific requirements for cholecystostomy drain care. Interviews revealed that the LPNs had not received training on this type of drain, and there was a lack of documentation regarding the output from the drain. The Director of Nursing was unaware of the staff's lack of understanding and reported that training would be provided by the Assistant Director of Nursing if needed.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative of changes in the resident's skin condition, which is a requirement according to the facility's Change of Condition policy. The policy mandates communication with the resident's representative in cases of unexpected deterioration in condition or status. In this instance, a resident with diagnoses including Type 2 diabetes mellitus, intrahepatic bile duct carcinoma, and gallbladder perforation was admitted with red buttocks, which later developed into an open area. A new physician order was received to treat a pressure ulcer, but the resident's representative was not informed of this change. The Licensed Practical Nurse (LPN) involved acknowledged that they did not contact the representative listed on the admission assessment, despite a family member being present during the treatment. The facility's policy requires charting the name of the person contacted, which was not done in this case. The Director of Nursing (DON) confirmed that the staff responsible for the admission assessment should ensure the contact information matches the face sheet in the electronic medical administration record (eMAR). The failure to notify the resident's representative of the new wound order constitutes a deficiency in the facility's adherence to its notification policy.
Failure to Update Care Plans with Smoking Interventions
Penalty
Summary
The facility failed to ensure that care plans were updated with smoking interventions for two residents who were sampled for smoking safety. Resident #2, who has a seizure disorder and bilateral below-knee amputation, was observed smoking unsupervised in the courtyard despite the facility's policy requiring supervision. The resident's care plan did not reflect the facility's change to allow smoking in the courtyard or include interventions to prevent unsupervised smoking. The resident's quarterly assessment indicated moderate cognitive impairment and tobacco use, and the administrator acknowledged the resident's history of noncompliance with supervised smoking. Resident #3, diagnosed with metabolic encephalopathy, was observed smoking with staff supervision, but their care plan lacked any mention of smoking activity or interventions. The resident reported being unable to open the door to the smoking area alone and required staff assistance. A smoking risk assessment for Resident #3 was completed on the same day as the observation, indicating that staff-supervised smoking would occur at designated times. The DON confirmed that smoking activity should be included in care plans and acknowledged that Resident #3's smoking assessment was missed upon admission.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was smoking, as required by their smoking policy. The policy, dated January 2024, mandates that all residents be supervised while smoking for their safety. Resident #1, who was identified as a smoker and at risk for injury, was observed smoking outside in the enclosed courtyard without staff supervision. The resident's care plan, dated September 2024, indicated that they should smoke only in designated areas and that their cigarettes and lighter should be kept at the nurse's station. Despite this, the resident was found smoking outside of the designated times and without supervision, as they admitted to saving a cigarette for unsupervised smoking after lunch. The administrator acknowledged that the resident was sometimes noncompliant with the smoking schedule and supervision requirements.
Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse and determine when to report the allegation for one of the sampled residents. The incident involved a resident who had returned from the hospital on hospice services. There were multiple reports from staff members indicating that a specific CNA was not allowed to provide care for this resident due to complaints of rough and rude treatment. Despite these reports, the facility's administration, including the Director of Nursing (DON), was not aware of an actual abuse allegation. The DON had been informed by the ombudsman about a complaint regarding rough treatment, but no formal investigation or reporting was initiated until a complaint survey brought the issue to light. The facility's policy on abuse, neglect, and exploitation requires timely investigation and reporting of all allegations to state and local agencies. However, in this case, the policy was not followed as the administration did not receive or act upon the abuse allegations regarding the resident and the CNA. The initial incident report was only created after the complaint survey notified the facility of a potential abuse allegation, leading to the suspension of the CNA and the initiation of an investigation.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. The deficiency was identified through record review and interviews, revealing that the facility was short of RN coverage during April and May 2024. Specifically, the facility lacked RN coverage for every Saturday and Sunday in May 2024 and two weekends in April 2024. The administrator confirmed that the Director of Nursing (DON) was hired in June 2024, and the Assistant Director of Nursing (ADON) was hired in February 2024, indicating staffing challenges during the months in question.
Deficiency in Food Handling and Staff Hygiene
Penalty
Summary
The facility failed to adhere to its policies regarding food preparation and staff hygiene, resulting in a deficiency. During an initial tour of the kitchen, a staff member was observed preparing the morning meal without a beard guard, contrary to the facility's Employee Infection Control policy, which mandates the use of beard guards for anyone entering the kitchen. The staff member admitted to not wearing the beard guard due to running late. Additionally, during lunch preparation, a cook and another staff member were observed handling food items, such as dinner rolls, with gloved hands instead of using clean tongs as required by the facility's General Food Preparation and Handling policy. The dietary supervisor confirmed that the staff should have used tongs when handling the dinner rolls.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as #42, who was reviewed for discharge. The resident had multiple diagnoses, including anemia, coronary artery disease, hypertension, non-Alzheimer's dementia, multiple sclerosis, depression, and chronic obstructive pulmonary disease. Despite being cognitively intact and independent in decision-making and activities of daily living, the resident was discharged without a complete discharge summary. The discharge summary lacked a recapitulation of the resident's stay, a final summary of the resident's status, and a reconciliation of all pre and post-discharge medications. The incident occurred when a CNA reported the resident missing, only to find out that the resident's contact had picked them up earlier, believing the resident was discharged. The resident had signed a NOMNC, which led to confusion about their discharge status. The DON noted that the responsible nurse did not document the discharge or complete the necessary summary, and this nurse was no longer employed at the facility. Attempts to contact the resident post-discharge were unsuccessful due to a disconnected phone number, and there was no documentation of communication with the resident's social worker regarding the discharge plans.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from eloping. The resident, who had diagnoses including dementia, diabetes mellitus, Parkinsonism, and anxiety, was identified as a moderate risk for elopement upon admission. Despite this, the resident exhibited combative behavior and expressed a desire to leave the facility, which was documented in the nurse's notes. On one occasion, the resident was found outside the front entrance but was redirected back inside. However, the facility did not consider this an elopement since the resident was still on the premises. On a subsequent occasion, the resident was found missing during routine rounds, and the facility initiated elopement procedures. The resident was eventually located at a nearby dealership parking lot and required medical care due to his condition. The facility's investigation revealed that the front door was unlocked, which allowed the resident to leave the premises. Staff interviews indicated that the resident had been verbalizing a desire to leave the facility and had been found outside the front door on a previous occasion. The facility's failure to lock the front door and adequately supervise the resident led to the elopement incident. The Administrator acknowledged that if the front door had been locked, it might have prevented the resident from eloping. The facility's investigation confirmed the need for immediate action to address the supervision and security lapses that allowed the resident to leave the premises unsupervised.
Removal Plan
- Resident #3 was placed on one-on-one supervision.
- The facility reassessed Resident #3's elopement risk and updated the care plan.
- The facility completed a headcount of all residents, reviewed all resident's elopement risk assessments and updated care plans.
- The elopement risk book kept at the nurse's station was reviewed and updated.
- The facility locked all the coded doors, changed the door codes to make them harder to figure out, and placed signage on all doors to not let residents out.
- Daily checks of doors were implemented.
- Staff members were in-serviced on elopement and keeping the doors locked.
- The facility conducted a root cause analysis exercise to determine the reason the elopement occurred.
Failure to Provide Correct Diet Leads to Hospitalization
Penalty
Summary
The facility failed to ensure a resident received food prepared to meet their dietary needs, resulting in hospitalization for aspiration pneumonia. The resident, who had a traumatic brain injury and required a pureed level 4 diet, was given food that did not meet these specifications. Despite having a care plan and physician orders indicating the need for a pureed diet, the resident was fed corn and other non-pureed items, leading to respiratory distress and subsequent hospitalization. On the day of the incident, a CNA, who was new to the facility, fed the resident corn and other foods that were not properly pureed. The resident experienced respiratory distress and was later diagnosed with aspiration pneumonia at the hospital. The facility's dietary manager and nursing staff were not adequately informed or did not take appropriate action to ensure the resident received the correct diet, as evidenced by the lack of documentation and communication regarding the choking incident. Interviews with staff revealed that there were previous instances where the resident received the wrong diet, but these were not properly reported or addressed. The facility's failure to consistently provide the correct diet and to communicate effectively among staff members contributed to the resident's hospitalization. The dietary manager mentioned plans to implement color-coded meal cards to prevent future incidents, but this was not yet in place at the time of the deficiency.
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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 Lawton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Park Health Care Center | 0.5 mi | ★★★★★ | 2 | 2 |
| Mcmahon-tomlinson Nursing Center | 1.3 mi | ★★★★★ | 4 | 0 |
| Lawton Post Acute & Rehab | 4.2 mi | ★★★★★ | 7 | 4 |
| Ayers Nursing Home | 27.2 mi | ★★★★★ | 0 | 0 |
| Temple Manor Nursing Home | 29.1 mi | ★★★★★ | 0 | 0 |
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