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 Pleasant Valley Health Care Center during CMS and state inspections, most recent first.
Resident Photos and Names Posted on Social Media: The facility failed to protect the privacy of 3 sampled residents when two former employees posted their photos and names on social media. The facility's policy prohibited sharing resident images without prior written permission, and staff interviews confirmed that resident photos and information should not be posted online without consent. The DON stated the employees were terminated before the facility became aware of the incident.
Failure to implement hourly toileting after a resident's fall. A resident with heart failure, urinary and bowel incontinence, and a history of falls was found on the floor after attempting to stand and said they needed to use the bathroom. Although the incident report stated an hourly toileting intervention was ordered after the fall, the MAR, TAR, and CNA task list showed no documentation that the intervention was carried out, and staff interviews confirmed the resident was being toileted every two hours instead.
An LPN administered Lantus via insulin pen to a resident with type 2 DM without priming the pen first. The LPN stated she did not know how to prime an insulin pen, and her skills checklist showed no evidence of training on insulin pen priming. The Medical Director stated insulin pens should be primed before use, and the DON said nurses administering insulin by pen should receive training on insulin administration.
Medication administration errors exceeded the allowable rate. An LPN gave Lantus without priming the insulin pen for a resident with type 2 DM, and a CMA administered amiodarone and diltiazem to another resident despite ordered hold parameters for BP and HR. Staff interviews confirmed the orders were not followed, and the facility's error rate was 8.82%.
Oxygen Tubing Not Stored Properly: A resident with a hx of acute respiratory failure with hypoxia had supplemental O2 ordered PRN for SOB, but surveyors observed the NC tubing on the floor under the concentrator on multiple occasions. The resident, who had intact cognition, said staff removed the O2 and placed the tubing somewhere. Facility policy required oxygen delivery devices to be covered in a plastic bag when not in use, and the DON and Administrator stated tubing should be stored in a bag.
Two residents with severe cognitive impairments were not evaluated for their capacity to consent to sexual activity, leading to an immediate jeopardy situation. Despite documented incidents of inappropriate sexual behavior, the facility failed to assess or document the residents' ability to consent, nor were care plans updated to address these behaviors. The facility's inaction resulted in a deficiency with potential for more than minimal harm.
The facility failed to ensure dignified mealtime assistance for two residents with cognitive impairments. Staff members were observed standing over residents while feeding them, contrary to the facility's policy that requires staff to be seated. The CNA involved was unaware of this policy, and the DON confirmed the expectation for staff to be seated during feeding assistance.
The facility did not ensure that information on filing complaints and contacting the Ombudsman was accessible to residents. During an interview, ten residents were unaware of how to contact the Ombudsman or report complaints. The information was posted on a bulletin board but was placed too high for easy access. The Administrator admitted the forms needed to be lowered.
The facility failed to make past survey results readily accessible to residents. Ten residents were unaware of where to find these reports. The survey results were placed in a binder on a bulletin board, mounted five feet above the floor, and attached to a chain, limiting access. The Administrator acknowledged the issue with the binder's height.
The facility failed to report abuse investigations and incidents involving three residents within the required timeframe. A resident with cognitive deficits reported verbal abuse by a CNA, but the incident was reported late. Another resident with intellectual disabilities experienced rough handling and alleged molestation, with delays in notifying the Nurse Aide Registry. A third resident with Alzheimer's was involved in unreported altercations and inappropriate behavior. The DON acknowledged the lack of reporting, citing residents' rights.
The facility failed to conduct thorough investigations into abuse allegations and resident altercations. A resident reported rough handling by staff, but the investigation was incomplete. Another resident was involved in multiple altercations without proper incident reporting or investigation. Additionally, an LPN allegedly used inappropriate language towards a resident, but the investigation was insufficient, and the incident was not reported to the nursing board.
Two residents with cognitive impairments exhibited inappropriate behaviors, including sexual misconduct and aggression, but their care plans were not updated to address these issues. Despite multiple documented incidents, the care plans lacked interventions or strategies to manage the behaviors, as confirmed by the DON.
The facility did not ensure RN coverage for eight consecutive hours daily, as required, affecting 83 residents. On several occasions in May, June, and July, RN coverage was insufficient, with hours worked ranging from 4.93 to 7.80 hours. Human Resources confirmed that the DON or ADON should cover these gaps, but this did not happen on the specified dates.
A facility failed to follow its policy for administering medications via enteral tube for a resident with a gastrostomy tube. A CMA was observed crushing medications into a powder without diluting them before administration, contrary to the policy requiring dilution and flushing with water. The CMA admitted to not following the procedure due to forgetting a spoon, despite being aware of the correct method.
The facility's medication error rate was 8.11%, exceeding the acceptable threshold of 5%. Two residents were affected: one was not instructed to chew a prescribed aspirin, and another did not receive Mylanta due to its unavailability and had issues with Potassium Chloride ER administration. These errors highlight a failure in medication administration protocols.
The facility failed to prevent bare hand contact with food during meal service for a resident with dementia, as a CNA used bare hands to serve bread. Additionally, the dishwashing machine was not properly monitored, resulting in inadequate chlorine levels for sanitation. The dietary manager resorted to using disposable serving items due to the issue.
The facility failed to prevent cross-contamination by improperly handling soiled linens and not using enhanced barrier precautions for a resident with a gastric tube. A CNA did not bag soiled items before transporting them, and a CMA did not don a gown when accessing a resident's gastrostomy tube, despite facility policies requiring these actions. Staff were unclear about the meaning of indicators for PPE use.
The facility failed to accurately code Resident Assessments for two residents. One resident, admitted to hospice care, had their hospice status omitted from the Annual Resident Assessment. Another resident, discharged home with family, was incorrectly documented as discharged to a hospital. These inaccuracies were confirmed by MDS Coordinators during reviews.
A resident with a stage four pressure wound did not receive a physician-recommended HBA1C test due to it being listed as a recommendation rather than an order. The test was pending for several months, and the oversight was only identified and addressed after a review by the facility's administration.
Resident Photos and Names Posted on Social Media
Penalty
Summary
The facility failed to ensure residents' private information was not released on social media for 3 of 3 sampled residents reviewed for privacy, involving Residents #2, #4, and #5. An undated Social Media Policy stated that photos or videos of a resident may not be posted, uploaded, sent, or otherwise shared or disclosed without prior written permission from the resident or the resident's authorized agent, including images where the resident is not easily identifiable. An incident report dated 07/21/26 stated a caller informed facility staff that two former facility employees had posted photos and names of the three residents on two social media platforms. During interviews on 07/24/26, an LPN stated resident photos and information should never be shared on social media without consent, a CNA stated resident photos should not be shared on social media, the DON stated they were not sure when the photos and names were posted and that the two employees had been terminated before the facility became aware of the incident, and the assistant administrator stated the former employees had failed to ensure resident privacy.
Failure to Implement Ordered Hourly Toileting After a Fall
Penalty
Summary
The facility failed to ensure a fall intervention to toilet a resident every hour was implemented for Resident #85. The resident was admitted on 04/16/2026 and had a medical history that included heart failure. The baseline care plan indicated the resident required one-person physical assistance for toilet use, was always incontinent of urinary continence, frequently incontinent of bowel continence, and had a history of falls. On 04/16/2026, the resident was found on the floor in front of their wheelchair near the nurses' station after attempting to stand, and the incident report stated the resident slipped, fell, landed on their buttocks, had no apparent injuries, and said they needed to go to the bathroom. The incident report stated that after the fall, the facility implemented an intervention to toilet the resident every hour. However, the MAR and TAR for 04/01/2026 - 04/30/2026 showed no documented evidence that the resident was checked for toileting every hour, and the task list report also showed no indication that CNA staff checked the resident every hour for toileting. During interviews, an LPN stated residents were checked for incontinence every two hours and that the resident was to be checked for toileting every hour after the fall, while another LPN stated every one-hour toileting would be documented in CNA tasks, MAR, or TAR but that staff toileted the resident every two hours. The DON stated the intervention after the fall was to toilet the resident every hour, but after reviewing CNA task orders, acknowledged there was not an every-hour toileting order and that the intervention was not implemented.
LPN Lacked Competency to Prime Insulin Pen
Penalty
Summary
The facility failed to ensure that a licensed practical nurse had the competency to administer insulin by pen for a resident with type 2 diabetes mellitus. Resident #76 had intact cognition with a BIMS score of 14 and was ordered Lantus 40 units subcutaneously daily. During medication administration observation, the LPN administered the Lantus insulin pen without priming it before injecting the dose into the resident's right lower abdominal quadrant. During interview, the LPN stated she had no knowledge of how to prime an insulin pen and was not sure how or why the process would be completed, and acknowledged she should have primed the pen if needed before giving the insulin. Review of the LPN's knowledge and skills checklist showed no evidence of training on how to prime an insulin pen. The Medical Director stated insulin pens should be primed before administration to get the air out of the needle, and the DON stated she would expect all nurses administering insulin by insulin pen to receive training on insulin administration.
Medication administration errors exceeded the allowable rate
Penalty
Summary
The facility failed to ensure the medication error rate was 5% or less, with 3 medication errors out of 34 opportunities for an error rate of 8.82%. The deficiency involved 2 residents observed during medication administration. Facility policy required medications to be administered according to physician orders and, when applicable, vital signs were to be obtained and medications held when vital signs were outside ordered parameters. The manufacturer's guidelines for the Lantus insulin pen also directed staff to perform a safety test by priming the pen before administration. One resident had type 2 diabetes mellitus and was ordered Lantus 40 units subcutaneously daily. During medication administration observation, an LPN administered the insulin without priming the Lantus pen first. During interview, the LPN stated she had no knowledge of how to prime an insulin pen and was not sure how or why the process would be completed, and stated she should have primed the pen before giving the insulin. The DON deferred her expectation to the ADON, and the ADON stated the pen should be primed with 2 to 3 units before the ordered dose was administered so air would be removed from the line and the resident would receive the correct dose. Another resident had diagnoses of essential hypertension and atrial fibrillation and was severely impaired in cognitive skills for daily decision making. The resident had orders for amiodarone and diltiazem with hold parameters for systolic blood pressure less than 120 mmHg or heart rate less than 60 bpm. During observation, a CMA administered amiodarone when the resident's heart rate was 62 bpm and diltiazem when the resident's systolic blood pressure was 101 mmHg. The CMA stated she did not notice the hold parameters before administering the medications and should have held them. The supervising LPN, the Medical Director, the DON, and the Administrator all stated the medications should have been read and followed according to the physician's orders.
Oxygen Tubing Not Stored Properly
Penalty
Summary
The facility failed to ensure a resident's supplemental oxygen tubing was stored in a plastic bag when not in use. Facility policy titled, Oxygen Administration, revised 06/03/2025, stated that oxygen delivery devices are to be covered in a plastic bag when not in use. Resident #41 was admitted on 10/02/2023 and had a history that included acute respiratory failure with hypoxia. The annual MDS dated 03/03/2026 showed a BIMS score of 15, indicating intact cognition, and the care plan identified the resident as at risk for altered respiratory status related to acute respiratory failure with hypoxia. The resident had an active order for supplemental oxygen at 2 L/M by NC as needed for SOB to maintain oxygen saturation greater than 90%. During observations on 06/08/2026, 06/09/2026, and 06/10/2026, the resident's oxygen tubing was seen on the floor under the oxygen concentrator in the resident's room. During a concurrent interview and observation, the resident stated they used oxygen at night when needed and said they were not aware of how the tubing got on the floor because they did not remove it, adding that staff took off the oxygen and placed the tubing somewhere. The DON stated she expected oxygen tubing to be stored in a zip lock bag, and the Administrator stated oxygen tubing should be appropriately stored inside a bag.
Failure to Evaluate Capacity for Consent in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to evaluate two residents for their capacity to consent to sexual activity, leading to an immediate jeopardy situation identified by the Oklahoma State Department of Health. Resident #18, who had a history of sexually inappropriate behaviors and was diagnosed with unspecified dementia, was observed engaging in sexual activity with Resident #51, who had severe cognitive impairment due to Alzheimer's Disease. Despite these observations, there was no documentation of an evaluation of their capacity to consent, nor were there care plans or assessments addressing their sexual activity. The facility's policy on Abuse, Neglect, and Exploitation, which includes guidelines for preventing sexual abuse and ensuring residents' capacity to consent, was not adhered to. The policy requires establishing a safe environment and documenting determinations of capacity to consent to sexual contact. However, the facility did not provide evidence of such evaluations or incident reports to the state health department, even after multiple incidents involving Resident #18's inappropriate sexual behaviors were documented in behavior notes. The Director of Nursing (DON) acknowledged that both residents had severely impaired cognitive abilities, yet no interventions were put in place to address the risk of sexual abuse or to update the residents' care plans to reflect their sexual behaviors. The facility's inaction in assessing and documenting the residents' capacity to consent to sexual activity, despite clear indications of cognitive impairment, resulted in a deficiency with the potential for more than minimal harm.
Removal Plan
- All staff are inserviced on sexual behaviors with residents with decreased BIMS and when to report incidents.
- Designee began assessing all BIMS greater than 9 in the facility for any sexual abuse from resident #18. All residents assessed had not had any form of sexual abuse while in the facility.
- Compliance with reporting allegations of abuse/neglect/exploitation policy has been reviewed with all staff. All staff have been inserviced and all new hires will continue to be inserviced upon hire.
- MDS updated Resident #18 care plan for sexual behaviors. Monitoring order in place every shift.
- Designee will review 24 hour reports and will report any new behaviors in morning meetings.
- Nurse Practitioner to evaluate and treat Resident #18. Resident evaluation to consent to sexual activity and sexual consent form was completed on Resident #18 and Resident #51.
- DON reviewed all behavior notes assessing for any resident to resident sexual abuse. No other instances were found.
- Resident #18 and Resident #51 were educated on sexual activity.
- Nursing staff will initiate the Evaluation for Sexual Consent Form upon any observed sexual behaviors between residents.
- Follow up regarding Resident #18 sexual consent, family consented to companionship but not the act of sex itself. Follow up regarding Resident #51: Family consented to companionship but not the act of sex itself.
Failure to Maintain Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to ensure that staff members assisted residents with eating in a dignified manner, as observed during meal service in the assisted dining room. Two residents, one with vascular dementia and obsessive-compulsive behavior, and another with unspecified dementia and mild neurocognitive disorder, were not assisted in accordance with the facility's policy. The policy, revised in July 2024, mandates that staff should be seated while feeding residents to promote and maintain dignity. However, during observations, staff members were seen standing over the residents while feeding them, which is contrary to the policy. Resident #12, who had severe cognitive impairment and was dependent on staff for eating, was fed by a CMA who stood over them, giving bites of food and drinks while standing. Similarly, Resident #75, who required supervision or touching assistance for eating, was fed by a CNA who also stood over them, despite an empty chair being available. The CNA was unaware of the policy regarding the positioning of staff while assisting residents with meals. The DON confirmed that staff should be seated while assisting residents with eating, indicating a lapse in adherence to the facility's policy.
Inaccessible Complaint and Ombudsman Information
Penalty
Summary
The facility failed to ensure that information on how to file a formal complaint with the state agency and contact the Ombudsman was readily accessible to residents. During a group interview with ten residents, it was revealed that none of them were aware of who their Ombudsman was or where to find information on how to contact them or report a complaint to the state survey office. The residents speculated that the information might be posted on a bulletin board in C Hall. Upon inspection, the bulletin board did contain the necessary information, but it was placed too high, with the bottom of the forms approximately 5 feet above the floor, making it difficult for residents to access. The Administrator acknowledged that the forms needed to be lowered to be more accessible to all residents.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that past survey results were readily available for residents to review. During a resident group interview, ten residents reported that they were unaware of where to find previous survey results and did not know they could access these reports. An observation revealed that the survey results were placed in a binder on a bulletin board in C Hall, mounted approximately five feet above the floor. The binder was attached to a chain, allowing it to be lowered only to about three feet above the floor, making it difficult for residents to access without assistance. The Administrator acknowledged that the binder might be positioned too high and needed to be relocated to a more accessible location.
Failure to Timely Report Abuse and Incidents
Penalty
Summary
The facility failed to report the results of abuse investigations to the State within the required 24-hour timeframe for three residents. Resident #15, who had a cognitive communication deficit and chronic kidney disease, reported verbal abuse by a CNA on July 3, 2024. However, the incident was not reported to the administration until July 8, 2024, and the final report was submitted on July 11, 2024. The delay was attributed to the CNA forgetting to report the incident in a timely manner. Resident #44, diagnosed with multiple conditions including mild intellectual disabilities and schizophrenia, reported rough handling by a staff member on June 26, 2024. Although the initial report was filed on the same day, the Nurse Aide Registry was not notified until July 2, 2024. Additionally, another incident involving an allegation of molestation by a CNA was reported late to the Nurse Aide Registry on August 20, 2024, after management became aware of the incident on August 19, 2024. Resident #51, with Alzheimer's Disease and severe cognitive impairment, was involved in several incidents that were not reported to the State. These included altercations with other residents and inappropriate sexual behavior with another cognitively impaired resident. Despite these events being documented in progress notes, no incident reports were filed with the State or other required agencies. The DON acknowledged that these incidents were not reported, citing the residents' rights as a reason for not taking further action.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving Resident #44, who reported that a staff member was too rough while providing care. The investigation was incomplete as it did not include interviews with all potential witnesses or other residents who might have been affected by the staff member involved. The Director of Nursing (DON) acknowledged the lack of a comprehensive investigation, admitting that not all necessary interviews were conducted to ensure the safety of all residents. Resident #51 was involved in multiple incidents of resident-to-resident altercations, including aggressive behavior and inappropriate sexual conduct. Despite these incidents being documented in progress notes, there were no corresponding incident reports or investigative notes in the clinical record. The DON confirmed that no investigations were initiated for these incidents, as they were not reported, highlighting a failure in the facility's process for handling resident altercations. Resident #14 reported an incident where an LPN allegedly used inappropriate language and gestures towards them. Although the LPN was initially suspended, the investigation was insufficient as it did not include interviews with other staff or residents who might have witnessed the incident. Furthermore, the facility did not report the LPN to the Oklahoma State Board of Nursing, as required by their abuse policy. The facility's failure to conduct a thorough investigation and report the incident to the appropriate authorities constitutes a deficiency in their handling of abuse allegations.
Failure to Revise Care Plans for Behavioral Issues
Penalty
Summary
The facility failed to revise care plans for two residents, #18 and #51, who exhibited significant behavioral issues. Resident #18, diagnosed with unspecified dementia, displayed inappropriate sexual behaviors on multiple occasions, including exposing themselves and attempting to touch others inappropriately. Despite these documented incidents, Resident #18's care plan did not include any interventions or strategies to address these behaviors. The care plan was last updated on 08/06/24, but it did not reflect the resident's ongoing behavioral issues. Similarly, Resident #51, diagnosed with Alzheimer's Disease and malignant neoplasm of the bronchus and lung, exhibited aggressive and inappropriate behaviors, such as yelling, swatting at other residents, and attempting to pull another resident out of a chair. Additionally, Resident #51 was involved in inappropriate sexual behavior with Resident #18. Despite these incidents, Resident #51's care plan did not address these behaviors or include any interventions. The Director of Nursing confirmed that the care plan did not cover the resident's behavioral issues.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days a week, as required. This deficiency was identified through observation, record review, and interviews. The facility, which housed 83 residents, did not meet the required RN coverage on multiple occasions in May, June, and July. Specific dates were noted where RN coverage fell short, with hours worked ranging from 4.93 to 7.80 hours instead of the mandated eight hours. Human Resource personnel confirmed that on days without adequate RN coverage, the Director of Nursing (DON) or Assistant Director of Nursing (ADON) would need to cover, but this did not occur on the listed dates.
Failure to Follow Medication Administration Policy via Enteral Tube
Penalty
Summary
The facility failed to adhere to its policy for administering medications via enteral tube for a resident with a gastrostomy tube. The policy required flushing the tube with water before and after administering medications, diluting medications appropriately, and using a clean oral syringe. However, during an observation, a Certified Medication Aide (CMA) prepared medications for a resident by crushing tablets into a fine powder and placing them into a plastic water cup without adding any liquids. The CMA then administered the medications through the gastrostomy tube without diluting them, contrary to the facility's policy. The CMA was observed using an eight-ounce container of tap water to flush the tube, mixing parts of the Jevity with the medications, and repeating the process until all medications and Jevity were administered. The CMA admitted to not diluting the medications due to forgetting to bring a spoon, despite being aware of the correct procedure. This incident involved a resident who had multiple medications prescribed, including clopidogrel bisulfate, lactulose, and Jevity, among others, to be administered via the gastrostomy tube.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 8.11%. This deficiency was identified during a survey where 37 medication administration opportunities were observed, and three errors were noted. Two residents were affected by these errors. Resident #43, who had a physician's order for a chewable aspirin to be taken daily for atherosclerotic heart disease, was not instructed to chew the aspirin as required. Instead, the medication was placed in a cup with other medications, and the resident swallowed it without chewing, as confirmed by the Certified Medication Aide (CMA) involved. Additionally, Resident #13, who had orders for medications to be administered via a gastrostomy tube, did not receive Mylanta as prescribed due to its unavailability. The CMA also failed to administer Potassium Chloride ER as ordered, citing that the medication could not be crushed and there were no alternative orders for administration through the gastrostomy tube. These actions and inactions contributed to the facility's failure to adhere to the required medication administration protocols, leading to the noted deficiency.
Deficiencies in Food Handling and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper food handling practices during lunch meal service, as observed with a resident diagnosed with unspecified dementia and mild neurocognitive disorder. The resident, who required supervision or assistance for eating, was served by a CNA who used bare hands to pick up and offer a slice of bread to the resident. The CNA was unaware of the policy regarding bare hand contact with food and later stated they would need to ask another staff member about it. The Director of Nursing mentioned that staff were allowed to touch food with bare hands if they sanitized their hands first, although this was not adhered to during the incident. Additionally, the facility did not adequately monitor the dishwashing machine to ensure proper sanitation. A dietary aide tested the chlorine level in the dishwashing machine, which showed a reading of 10 ppm, below the required 50-100 ppm. The dietary manager confirmed the inadequate chlorine level and called maintenance for assistance. In the meantime, the dietary manager decided to use paper serving containers and plastic utensils for lunch service due to the improper sanitation of dishes.
Infection Control Deficiencies in Linen Handling and Barrier Precautions
Penalty
Summary
The facility failed to handle soiled linens properly, leading to potential cross-contamination. During an observation, a CNA provided incontinent care to a resident with cognitive communication deficit and persistent mood disorder. The resident was found with stool on their buttock and back, and the CNA removed the soiled shirt and sling, tossing them on the ground instead of bagging them as per the facility's policy. The CNA later placed the soiled items on the lid of a soiled linen barrel in the hallway without bagging them, contrary to the facility's laundry services policy. Additionally, the facility did not ensure the use of enhanced barrier precautions when accessing a resident's gastric tube. A CMA administered medications and nutritional supplements to a resident with a gastrostomy tube and ESBL resistance without donning a gown, as required by the facility's enhanced barrier precautions policy. The CMA was unaware of the meaning of the green star on the resident's door, which indicated the need for enhanced barrier precautions. This lack of understanding was also evident among other staff members, as an LPN was unsure of the PPE requirements and the significance of the green star.
Inaccurate Resident Assessments for Hospice and Discharge Status
Penalty
Summary
The facility failed to ensure accurate coding of Resident Assessments for two residents. Resident #58, diagnosed with dysphagia following a cerebral infarction, was admitted to hospice care as per a physician's order. However, the Annual Resident Assessment did not document the hospice care received, despite the MDS Coordinator acknowledging that the life expectancy less than six months section was marked, but hospice care was not. Similarly, Resident #85, who had a displaced intertrochanteric fracture of the left femur, was discharged home with family, as noted in a Nurses' Note. However, the Discharge Resident Assessment inaccurately documented the discharge status as a short-term general hospital, which was confirmed by MDS Coordinator #2 upon review.
Failure to Obtain Physician-Ordered Lab Test
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were obtained for a resident with a stage four pressure wound on the left heel. The Wound Care Physician recommended an HBA1C test in the Wound Evaluation and Management Summary notes starting from May 15, 2024. However, subsequent notes on multiple dates indicated that the HBA1C was pending, and there was no documentation that the test was ever obtained. The issue arose because the HBA1C was listed under recommendations rather than orders, leading to the wound care nurse not seeing it. The Administrator confirmed that the test was only ordered on August 15, 2024, after the oversight was identified.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 42 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Muskogee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartway At York Manor Health And Rehab | 0.7 mi | ★★★★★ | 0 | 0 |
| Broadway Care & Rehab Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Muskogee Nursing Center | 1.2 mi | ★★★★★ | 1 | 1 |
| Eastgate Village Care & Rehab Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Brentwood Extended Care & Rehab | 4 mi | ★★★★★ | 0 | 0 |
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