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 Nowata Nursing Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment was transferred to the hospital for increased confusion, hallucinations, and respiratory changes after receiving one-half of a Xanax tablet from a family member, despite having no Xanax order in the EMR or MAR. An LPN learned from the family member that they had given the resident their own Xanax and relayed this to another LPN, who confirmed the incident with the family member and notified ambulance staff. The administrator was informed and discussed the event with the DON and a corporate nurse but decided it was not reportable because the state incident form did not specifically address this type of event, resulting in the failure to report an alleged criminal act involving a controlled substance to state authorities and law enforcement within the required 2-hour timeframe.
The facility did not submit the required staffing data to CMS for the third quarter of 2024. The administrator, who was responsible for entering the data, failed to ensure its upload due to the usual staff member being out ill. The facility had 34 residents during this period.
The facility failed to provide accurate CMS-10055 forms to two residents discharged from Part A services. One form lacked estimated costs and the resident representative's choice, while another did not specify the type of skilled services billed to Medicare. The ADON admitted the omissions were errors.
The facility failed to implement gradual dose reductions and PRN limitations for psychotropic medications. A resident was prescribed an antianxiety medication on a PRN basis without a 14-day limit or justification for extended use. Two residents on antidepressants did not have documented attempts or recommendations for gradual dose reductions, contrary to facility policy. The ADON acknowledged these oversights.
The facility failed to ensure kitchen staff with beards wore beard guards while preparing food. Observations revealed the dietary manager and a dietary aide working without beard guards, and the dietary manager confirmed the absence of beard guards in the facility. The administrator was unaware of this issue and acknowledged the requirement for beard guards during food preparation.
The facility did not implement its Enhanced Barrier Precautions (EBP) policy to prevent MDRO spread. No signage was observed on resident doors, and staff were unaware of EBP procedures. The ADON acknowledged that EBP was not consistently used.
A facility failed to provide a written notice of transfer to a resident before their transfer to an acute care hospital. The resident was sent to the hospital for confusion and low blood oxygen saturation, with a family member notified. However, the resident did not receive a written notice of transfer. Interviews with staff revealed they were unaware of the requirement for such a notice.
A facility failed to provide a written notice of the bed hold policy to a resident transferred to a hospital. The facility's policy requires informing residents or their representatives in writing before transfers. However, a resident sent to an acute care hospital for confusion and low blood oxygen saturation did not receive this notice. Staff confirmed the oversight, and the ADON found no documentation of the notice being given.
Failure to Report Unauthorized Administration of Controlled Substance to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of a crime toward a resident to the state survey agency and local law enforcement within the required 2-hour timeframe. Facility policy dated 10/11/22 required all allegations of abuse, neglect, misappropriation of resident property, exploitation, injuries of unknown source, and suspected criminal acts to be reported to appropriate authorities within required time frames. Resident #4 had a quarterly assessment dated 04/18/25 showing a BIMS score of 12, indicating moderate cognitive impairment. On 06/24/25, a Transfer to Hospital Summary documented that the resident was transferred due to increased confusion, hallucinations, shortness of breath, and abdominal breathing of 30 breaths per minute, and that the nurse had informed the hospital that the resident had received one-half of a Xanax tablet from a family member. Review of the resident’s EMR and medication records showed there was no order for Xanax for this resident. During interviews, one LPN stated that during a lunch break a family member told them they had given the resident one of their own Xanax tablets because the resident was yelling out for their deceased husband. The LPN reported that they informed another LPN, who was arranging the resident’s transfer to the hospital, about the Xanax, and that ambulance staff were notified. The second LPN recalled being informed that a specific family member had given the medication, and stated they called that family member, who confirmed giving the tablet and explained why. The administrator stated they were informed of the incident by the DON at the time, and that they and the corporate nurse discussed whether to report it but decided it was not reportable because there was no place for such an incident on the state incident reporting form. The administrator later acknowledged that if someone administered their personal controlled substance to a resident, it should have been reported as a criminal activity and that they had not fully followed the facility’s abuse policy.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required direct care staffing data to CMS for the third quarter of 2024, covering the period from April 1, 2024, to June 30, 2024. This deficiency was identified through a review of the PBJ Staffing Data Report, which documented the absence of the mandated submission. During an interview on November 20, 2024, the administrator acknowledged responsibility for entering the data for the third quarter but admitted to not following up to ensure the data was uploaded to CMS. The administrator explained that the usual person responsible for uploading the data was out ill, and they had attempted to input the data remotely. The facility had 34 residents at the time of the deficiency, as stated by the ADON.
Failure to Provide Accurate CMS-10055 Forms
Penalty
Summary
The facility failed to provide accurate CMS-10055 forms to two residents who were discharged from Part A services. For one resident, the form was approved via telephone by the resident's representative but did not document the estimated costs if the resident wished to continue the identified skilled services. Additionally, the form lacked the resident representative's choice regarding whether to continue the services and bill Medicare for an official decision, continue services and bill the resident, or end the services. For the second resident, the form included the resident's signature but did not specify the type of skilled services to be billed to Medicare. The Assistant Director of Nursing (ADON) acknowledged that they had forgotten to include the necessary information on the forms for these residents. The ADON stated that the purpose of the document was to inform residents about the type of services to be provided and their financial responsibility, if any. The omission of this information was identified as an error on the part of the facility.
Failure to Implement Gradual Dose Reductions and PRN Limitations for Psychotropic Medications
Penalty
Summary
The facility failed to adhere to regulations regarding the prescription and management of psychotropic medications for residents. Specifically, an antianxiety medication was prescribed on an as-needed basis without a 14-day limit or a physician's explanation for its continued use beyond 14 days for one resident. Additionally, the facility did not attempt or recommend gradual dose reductions for antidepressants for two residents, despite the facility's policy requiring such actions unless contraindicated. The Assistant Director of Nursing (ADON) acknowledged the oversight regarding the PRN antipsychotic order and the lack of documentation for gradual dose reductions. Resident #17, diagnosed with recurrent depressive disorder, was prescribed citalopram hydrobromide, an SSRI, without any documented attempt or recommendation for a gradual dose reduction. Resident #24, with an anxiety disorder, was prescribed lorazepam on a PRN basis without a 14-day limit or justification for extended use. Resident #30, diagnosed with major depressive disorder, was prescribed trazodone without any documented attempt or recommendation for a gradual dose reduction. The ADON confirmed the absence of pharmacy recommendations or physician attempts for dose reductions for these residents.
Failure to Use Beard Guards in Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff with beards wore beard guards while preparing food for residents. During observations on two separate occasions, the dietary manager and a dietary aide were seen working in the kitchen without beard guards. The dietary manager admitted that the facility did not have any beard guards available. The administrator was unaware of the lack of beard guards and acknowledged that they were required when preparing food.
Failure to Implement Enhanced Barrier Precautions for MDROs
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy to prevent the spread of Multi-Drug Resistant Organisms (MDROs). The policy, revised in July 2022, required the use of personal protective equipment (PPE) during high-contact care activities for residents with indwelling medical devices or colonized infections with MDROs. During a facility tour, no signage was observed on resident doors indicating the implementation of EBP for at-risk residents. Interviews with staff revealed a lack of awareness and understanding of EBP. A Certified Medication Aide (CMA) stated that enhanced barrier precautions were not in place, and a Certified Nursing Assistant (CNA) was unaware of what EBP was or how to use it. The Assistant Director of Nursing (ADON) admitted that the facility was still in the process of implementing EBP and that it was not being used consistently.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident prior to their transfer to an acute care hospital. This deficiency was identified for one of two sampled residents reviewed for hospitalizations and discharges. According to the facility's Transfer or Discharge Notice policy, notice should be given as soon as practicable before the transfer or discharge when it is necessary for the resident's welfare. On August 27, 2024, a progress note documented that a resident was sent to a hospital for confusion and low blood oxygen saturation, with a family member notified of the situation. However, the resident did not receive a written notice of transfer. Interviews with RN #1, LPN #1, and the ADON revealed that they were unaware of the requirement for a written notice of transfer, and no such notice was provided to the resident at the time of the transfer.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to a resident when they were transferred to a hospital. The facility's Bed-Hold and Returns policy, dated March 2017, requires that residents or their representatives be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves. However, during a review of records and interviews, it was found that Resident #32, who was sent to an acute care hospital on 08/27/24 due to confusion and low blood oxygen saturation, did not receive this written notice. Both RN #1 and LPN #1 confirmed that they did not provide the written notice to the resident at the time of transfer. The ADON also confirmed the absence of documentation regarding the issuance of the bed hold policy notice for Resident #32.
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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 Nowata
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Osage Nursing Home, Llc | 0.3 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Adams Parc | 15 mi | ★★★★★ | 0 | 0 |
| Heritage Villa Care & Rehab Center | 16 mi | ★★★★★ | 5 | 0 |
| Bartlesville Health And Rehabilitation Community | 16.6 mi | ★★★★★ | 1 | 1 |
| Forrest Manor Nursing Center | 17.6 mi | ★★★★★ | 0 | 0 |
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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 July 2026) and official state health department websites.