Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Noble Health Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of cerebral infarction was found with their call light out of reach while seated, contrary to facility policy and their fall care plan. Staff confirmed the call light was not accessible and acknowledged the requirement to keep it within reach.
During incontinent care, two CNAs did not change gloves between handling soiled and clean items for a resident with cognitive deficits following a cerebral infarction. Both staff members continued care without changing gloves after cleaning fecal matter and before applying clean pads and briefs, contrary to infection control protocols. Staff interviews confirmed awareness of the correct procedure.
Multiple residents experienced physical and verbal abuse from another resident, including hitting, spitting, and derogatory language. Staff intervened during several incidents, but the aggressive behavior persisted, resulting in injuries and fear among residents. The facility did not ensure a safe environment free from abuse as required by policy.
A facility failed to perform weekly skin assessments for a resident at risk for skin breakdown, as required by their policy. The resident, who had type II diabetes and dermatitis due to incontinence, had a care plan intervention for weekly skin inspections. Despite a physician's order for wound dressing paste to manage MASD, assessments were not documented for two weeks. The resident required substantial assistance with toileting and was always incontinent, increasing the risk of skin issues. The lapse was confirmed by the wound care nurse and DON.
The facility failed to maintain a clean environment, as observed in multiple resident rooms. A resident reported their restroom was dirty, with grime and debris present. Housekeeping was observed inadequately cleaning another resident's room, and it was reported that rooms were cleaned every other day, contrary to the administrator's statement that cleaning should occur daily. The DON and RN confirmed the inadequate cleaning.
A housekeeper failed to follow infection control measures by carrying a resident's ice cup without a lid and with their thumb inside after cleaning rooms. The cup was also placed on wet floor signs on a cart, compromising its cleanliness. The DON acknowledged these actions as improper infection control practices.
The facility failed to monitor a resident with COVID-19, lacking documentation and orders for respiratory status checks until days after diagnosis. Another resident with a PICC line for IV therapy had no documented care plan or orders for monitoring and management, including dressing changes. The DON confirmed the absence of necessary orders and documentation.
The facility failed to provide palatable and properly temperature-controlled meals to residents, with reports of cold food, lack of variety, and discrepancies between the menu and served items. Observations showed food trays left in hallways, lukewarm meals, and diluted juices due to a malfunctioning machine. A dietary aide admitted to not taste-testing the food, and the dietary lead acknowledged issues with meat preparation and juice calibration.
The facility did not comply with its Food Storage policy, as observed with unlabeled and improperly stored food items. A container of sugar was left open, a bag of flour was ripped, and several food items in the refrigerator and freezer lacked labels and dates. The DM acknowledged these issues, indicating a need for proper storage solutions.
A facility failed to follow enhanced barrier precautions during wound care for a resident with a stage 4 pressure ulcer, as an LPN did not wear a gown or perform hand hygiene. Additionally, a CMA did not perform hand hygiene during a medication pass and touched medications with bare hands, while personal food and drink were found on the medication cart.
The facility did not maintain an effective antibiotic stewardship program and infection surveillance from April to June 2024. The policy required detailed documentation of antibiotic prescriptions and infection criteria, but this was not done for six residents. The DON confirmed the absence of necessary documentation during this period.
The facility failed to ensure resident dignity during mealtime as staff were observed standing over residents while assisting them with eating, despite available seating. A CMA and a CNA were seen standing while helping residents, contrary to the facility's policy of sitting at eye level. The DON confirmed staff were aware of this policy.
The facility did not ensure that two residents, one with a traumatic brain injury and another with hemiplegia and acute kidney failure, were offered the choice to formulate an advance directive upon admission. The DON confirmed the absence of these documents in the residents' charts, attributing the issue to potential misplacement in an old chart.
A facility failed to accurately code MDS assessments for a resident with a traumatic brain injury, nephrolithiasis, and left upper extremity paralysis. Despite documentation and a physician's order indicating the presence of an indwelling catheter, the MDS assessments inaccurately recorded no bowel or bladder appliances. The MDS Coordinator confirmed the coding errors.
A resident with a history of right femur fracture and spinal disc disorder experienced an unwitnessed fall, resulting in a bruise on the head. The facility's policy required neurological checks to be conducted for 72 hours following such incidents. However, the neuro check log showed that checks were not completed for 16 out of 18 opportunities. The DON confirmed the failure to adhere to the protocol.
A facility failed to obtain a physician order for the placement of a foley catheter for a resident who was readmitted with sepsis. Although a progress note indicated the catheter was inserted per provider order, a review of physician orders did not document this. The resident was observed with a foley catheter drainage bag, and the DON confirmed the nurse did not enter an order before placement.
A resident with COPD was left unsupervised during a breathing treatment, despite not being assessed to self-administer medications. The resident reported that nurses never stay to monitor them, and an LPN confirmed that supervision is required unless self-administration is assessed. The DON stated that nurses should remain with residents during such treatments.
A facility failed to consistently monitor psychotropic medications for a resident with anxiety disorder. Despite having physician orders for mirtazapine, buspirone, and fluoxetine, documentation of behavior and side effect monitoring was frequently missing over several months. The DON confirmed the inconsistency in monitoring.
Call Light Not Kept Within Resident's Reach
Penalty
Summary
A deficiency was identified when a resident's call light was observed to be out of reach while the resident was seated in their chair. The call light was found on the floor by the head of the bed, and the resident, who had moderate cognitive impairment and a history of frontal lobe and executive function deficit following a cerebral infarction, stated they could not see or access the call light. The facility's policy and the resident's fall care plan both required that the call light be kept within the resident's reach. Staff interviews confirmed that the call light was not in reach and that the process was to ensure it was accessible to the resident.
Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
During an observation of incontinent care for a resident with a history of frontal lobe and executive function deficit following cerebral infarction, two CNAs failed to maintain proper infection control practices. After cleaning the resident's abdominal folds and peri area, including removal of fecal matter and a soiled brief, CNA #1 did not change gloves before placing a new pad under the resident. CNA #2 also handled both soiled and clean items without changing gloves. The process continued with the same gloves until the brief tab tore, at which point CNA #1 removed gloves and left the room to retrieve a new brief. Both CNAs acknowledged during interviews that gloves should have been changed between dirty and clean tasks, and the DON confirmed this protocol.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from abuse, as evidenced by repeated incidents involving one resident who physically and verbally assaulted others. Four residents, all with varying levels of cognitive impairment, reported or were observed to have experienced physical aggression, verbal abuse, and threats from another resident. These incidents included hitting, spitting, yelling, and derogatory language directed at both residents and staff. In one instance, a resident was observed with dried blood and a scratch on their ear after being struck, while another resident reported being spit on and threatened. Documentation and interviews revealed that the aggressive resident had a history of altercations, including hitting another resident in the head, spitting in a resident's face, and pushing a walker against another resident's wheelchair. Staff were present during several of these events and attempted to intervene by separating residents and de-escalating situations. Despite these interventions, the aggressive behavior persisted, and multiple residents expressed fear and distress, with some stating they felt unsafe or threatened by the resident in question. The facility's policy prohibits abuse, neglect, and exploitation by anyone, including residents. However, the repeated nature of the incidents, the physical injuries observed, and the ongoing verbal abuse indicate that the facility did not ensure a safe environment free from abuse for all residents. The aggressive resident's actions were documented in incident reports, and staff and administrative interviews confirmed the ongoing challenges in managing the situation, but the abuse continued to affect multiple residents.
Failure to Perform Weekly Skin Assessments
Penalty
Summary
The facility failed to perform weekly skin assessments for a resident, identified as #4, who was at risk for skin breakdown. The facility's policy required licensed nurses to conduct a head-to-toe skin check weekly, paying attention to areas in contact with the bed, chair, or any orthotic devices, and to document any significant findings. Despite this policy, there were no documented skin assessments for the weeks of November 11 and November 18, 2024, for the resident, who had a history of type II diabetes mellitus, rash, and irritant contact dermatitis due to incontinence. The resident's care plan specifically included an intervention to inspect and document the skin condition weekly. The resident had a physician's order for the application of Triad wound dressing paste twice daily to manage moisture-associated skin damage (MASD) on the buttocks. The resident was cognitively intact but required substantial assistance with toileting and was always incontinent of bowel, which increased the risk of skin issues. Despite these needs, the required weekly skin assessments were not completed, as confirmed by the wound care nurse and the Director of Nursing (DON). The resident was eventually transported to the hospital on November 20, 2024, and did not return to the facility.
Failure to Maintain Clean Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations and resident reports. Resident #2 reported that their restroom was dirty, and upon inspection, the restroom sink was found to be brown with grime, with brown rings on the countertop and black debris on the floor. Housekeeper #1 was observed not sweeping the floor and inadequately mopping Resident #6's room. Resident #6 reported that their room and restroom were only cleaned every other day, and the sink and toilet were cleaned only upon request. The administrator confirmed that all resident rooms and restrooms should be cleaned daily, but acknowledged the presence of stains and grime in the restrooms. Further observations revealed that the toilet riser in Resident #6's room was soiled with dried stool, and the sink was covered with brown grime that could be easily wiped away. The floor in the restroom also had black debris. Housekeeper #1 confirmed that resident rooms and bathrooms were cleaned every other day, contrary to the administrator's statement. The DON and RN #1 agreed that the restroom in Resident #6's room had not been cleaned properly, indicating a failure in housekeeping services to maintain a clean environment for the residents.
Infection Control Breach in Ice Handling
Penalty
Summary
The facility failed to ensure proper infection control measures were followed by staff when obtaining ice for a resident. A housekeeper was observed carrying a resident's ice cup down the hallway to the ice machine without a lid, with their thumb inside the cup. Prior to this, the housekeeper had been cleaning rooms, which raises concerns about potential contamination. Additionally, the housekeeper placed the resident's ice cup on top of wet floor signs on the housekeeping cart, further compromising the cleanliness of the cup. The Director of Nursing (DON) was informed of these actions and acknowledged that they did not adhere to proper infection control practices.
Deficiencies in COVID-19 Monitoring and PICC Line Management
Penalty
Summary
The facility failed to adequately assess, monitor, and intervene for a resident who tested positive for COVID-19. The resident, who was cognitively intact and had a history of weakness and difficulty swallowing after a stroke, was sent to the hospital with symptoms of difficulty breathing, fever, and diminished lung sounds. Upon returning to the facility with a COVID-19 diagnosis, there were no progress notes or orders to monitor the resident's respiratory status until several days later. It was only on a later date that a physician order was documented to monitor the resident's respiratory status every eight hours, along with other vital signs. Additionally, the facility did not properly manage a resident with a PICC line, who was severely cognitively impaired and readmitted with sepsis. Despite receiving antibiotics through the PICC line, there was no documentation of dressing changes, monitoring, or management of the PICC line. The care plan did not include interventions for the PICC line, and there was no order to discontinue or change the dressing. The DON acknowledged the lack of orders for monitoring the PICC site and changing the dressing every seven days, and there was no documentation of when or by whom the PICC line was discontinued.
Deficiency in Food Service Quality
Penalty
Summary
The facility failed to ensure that food was palatable and served at appetizing temperatures during meals, affecting the quality of service provided to 80 residents. Multiple residents expressed dissatisfaction with the food, citing issues such as cold temperatures, lack of variety, and discrepancies between the menu and what was served. Observations revealed that food trays were left sitting in the hallway for extended periods, contributing to the food being served cold. Additionally, a resident was observed with an unopened tray out of reach, indicating a lack of staff assistance during meal times. Further investigation showed that the food served was not at appropriate temperatures, with items like sweet potatoes and pork being lukewarm and unappetizing. The pork was noted to have a large amount of fat and gristle, and the juices were diluted due to a malfunctioning juice machine. A dietary aide admitted that the food was not taste-tested before serving, and the dietary lead acknowledged that the meat should have been trimmed and the juice machine calibrated. These findings highlight a failure in the facility's food service processes, impacting the residents' dining experience.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its Food Storage policy, which mandates that all opened food packages be stored in air-tight containers or bags and accurately labeled with the item and date opened. During an observation, a container labeled as sugar was found with its lid completely open, and a large bag of flour was discovered ripped open with more than half of its contents missing. Additionally, unmarked containers in the refrigerator were suspected to contain jello and cream corn, but they lacked labels and dates. Premade ice cream snacks in the freezer were also found without labels or dates. The Dietary Manager (DM) and another staff member acknowledged these issues, with the DM expressing uncertainty about why the sugar was left open and admitting the need for a proper container for the flour.
Infection Control Lapses in Wound Care and Medication Pass
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions during wound care for a resident with a stage 4 pressure ulcer, congenital scoliosis, and contractures. The resident required enhanced barrier precautions, including the use of gowns and gloves for high-contact activities such as wound care. However, during an observation, an LPN did not wear a gown and failed to perform hand hygiene at any point while providing wound care. The LPN acknowledged the oversight, expressing regret for not following the proper protocol. Additionally, during a medication pass, a CMA was observed not performing hand hygiene before and after resident interactions and touching medications with bare hands. Personal food and drink were also found on the medication cart, which is against facility policy. The CMA admitted to the lapses in protocol, acknowledging that hand hygiene should be performed before and after each resident interaction and that medications should not be handled with bare hands. The ADON confirmed these expectations, emphasizing the importance of maintaining proper infection control practices.
Failure in Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program and infection surveillance from April 2024 through June 2024. The facility's policy required documentation of prescription details, including dose, duration, route, and indication, in the medical records of all residents prescribed antibiotics. Additionally, the policy mandated the use of McGreer's Criteria for infection surveillance and monthly data compilation for review by the Quality Committee. However, during the review, it was found that there was missing documentation of McGreer's criteria, symptoms, and organism from culture for the specified period. The Director of Nursing (DON) confirmed the absence of documented antibiotic stewardship and infection surveillance during this time frame. Six residents were identified as having been prescribed antibiotics, but the necessary documentation was not maintained as per the facility's policy.
Failure to Promote Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to promote resident dignity by having staff stand over residents while assisting them with eating. During an observation, a CMA was seen standing while helping two residents at a dining table, and a CNA was also standing while assisting another resident at a nearby table. Despite the availability of empty chairs nearby, these staff members did not sit down. Another staff member was observed seated while feeding residents. The CMA later stated they were unaware of the requirement to sit, as they usually worked the night shift, and mentioned they were trying to prevent food from being scooped off the plate. The DON confirmed that the facility's policy is for staff to sit at eye level with residents during feeding, and staff were aware of this policy.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate an advance directive, as required by their policy. This deficiency was identified during a review of records and interviews, where it was found that two residents, one with a traumatic brain injury and another with hemiplegia and acute kidney failure, did not have their advance directives documented upon admission. The Director of Nursing (DON) confirmed that the advance directives were not uploaded for these residents and acknowledged that they were unable to locate them initially. The issue was attributed to the possibility of one resident's advance directive being in an old chart.
Inaccurate MDS Coding for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure accurate coding of resident assessments on the Minimum Data Set (MDS) for one resident out of a sample of 19. The resident in question had a medical history that included traumatic brain injury, nephrolithiasis, and left upper extremity paralysis. Documentation from a Resident Summary indicated that the resident had an indwelling catheter on multiple dates. Additionally, a physician's order confirmed the presence of a Foley catheter. However, the quarterly MDS assessments inaccurately documented that the resident had no bowel or bladder appliances. The MDS Coordinator acknowledged that the assessments conducted on two separate occasions were incorrectly coded, failing to reflect the resident's use of an indwelling catheter.
Failure to Complete Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its INCIDENT/ACCIDENT REPORTING policy by not completing neurological checks per protocol after an unwitnessed fall involving a resident. The policy, reviewed on 01/12/22, mandates that a neurological assessment flow sheet be initiated and maintained for 72 hours following any incident involving a head injury or unwitnessed fall. A resident, admitted with a history of right femur fracture and spinal disc disorder, experienced an unwitnessed fall on 07/04/24, resulting in a small bruise on the top right side of the head. Although the incident report indicated that neuro checks were started, the neuro check log revealed that checks were not completed for 16 out of 18 opportunities. The Director of Nursing confirmed on 08/08/24 that the neuro checks were not conducted as per the protocol for the fall on 07/04/24.
Failure to Obtain Physician Order for Foley Catheter Placement
Penalty
Summary
The facility failed to obtain a physician order for the placement of a foley catheter for one of the three sampled residents reviewed for catheters. The resident was readmitted to the facility with a diagnosis that included sepsis. A progress note documented that a foley catheter was inserted per provider order, but a review of physician orders from the specified dates did not document an order for the placement of a foley catheter. The resident was observed with a foley catheter drainage bag hanging from their wheelchair. The Director of Nursing stated that the nurse did not enter an order to place the foley before it was placed.
Failure to Supervise Resident During Breathing Treatment
Penalty
Summary
The facility failed to supervise a resident during the administration of a breathing treatment. The resident, who had a diagnosis of COPD, was observed holding a breathing treatment mask to their face without a nurse present. The resident reported that the nurse set up the treatment and left, and that nurses never stay to monitor them during the treatment. The resident did not have an assessment to self-administer medications. An LPN confirmed that the resident should be monitored during the treatment unless assessed to self-administer. The Director of Nursing stated that the nurse should stay with the resident during the administration of a breathing treatment.
Inconsistent Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring of psychotropic medications for a resident diagnosed with anxiety disorder. The resident had physician orders for mirtazapine, buspirone, and fluoxetine to manage their condition. However, the facility did not consistently document behavior and side effect monitoring for these medications. Specifically, there were 25 instances of missing documentation out of 60 opportunities in June, 25 out of 62 in July, and 11 out of 14 in early August. The Director of Nursing acknowledged the inconsistency in monitoring during an interview.
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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 Noble
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holiday Heights Healthcare | 6.2 mi | ★★★★★ | 0 | 0 |
| 24th Place | 6.3 mi | ★★★★★ | 13 | 1 |
| Ignite Medical Resort Norman, Llc | 7.7 mi | ★★★★★ | 0 | 0 |
| Grace Skilled And Nursing Therapy Norman | 8 mi | ★★★★★ | 3 | 0 |
| Medical Park West Rehabilitation & Skilled Care | 8.3 mi | ★★★★★ | 1 | 0 |
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