Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Pocola Health And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral disturbances repeatedly engaged in inappropriate sexual behaviors with other cognitively impaired residents. Despite staff interventions and the facility's policy requiring prevention and investigation of abuse, supervision was inconsistently applied, and documentation of one-on-one monitoring was missing for extended periods. Staff interviews confirmed lapses in monitoring, resulting in the facility's failure to protect residents from sexual abuse.
Surveyors found that the facility did not provide copies of its bed-hold policy to two residents when they were transferred to the hospital, including one with severe cognitive impairment and another with moderate cognitive impairment who was hospitalized for acute cystitis. Documentation showed the residents were sent to the ER and one was later readmitted, but there was no record of bed-hold policy notification at the time of transfer. An LPN stated they did not give residents the bed-hold policy when sending them to the hospital, and the DON confirmed that the policy was only reviewed at admission and not reissued during subsequent hospital transfers.
A resident with anxiety disorder and depression had a PRN order for Ativan 0.5 mg every 12 hours for anxiety that lacked an end date and was not limited to 14 days as required by facility policy. A pharmacy consultant identified the PRN psychoactive medication as potentially constituting a chemical restraint and requested physician documentation of rationale and a specific duration for any extension, but the physician chose to keep the PRN order without providing the required handwritten rationale or duration. A quarterly assessment showed the resident had intact cognition and was receiving an antianxiety medication, while an LPN and the DON both acknowledged that PRN psychotropic medications should be time-limited to two weeks unless a physician documents justification and duration, demonstrating noncompliance with the facility’s own standards.
A resident receiving continuous enteral nutrition via pump had a tube feeding bag running at 50 ml/hr on multiple observations without any label. A CMA and an LPN both reported they could not determine which resident the unlabeled bag was intended for or when it had been hung, and acknowledged that the bag should have been labeled. The DON also confirmed they could not identify the intended resident or the time and date the feeding was started because the bag lacked a label, despite stating that such bags should be labeled.
A resident with severe cognitive impairment and a history of vascular dementia was administered another resident's medications by a CMA, resulting in hospitalization for adverse reactions including hypotension and hyponatremia. Review of staff files and interviews revealed that CMAs had not received regular competency evaluations, and medication administration was not routinely observed by the DON. A similar medication error involving the same resident had previously occurred without effective follow-up.
A resident with severe cognitive impairment and multiple medical conditions was administered another resident's medications by a CMA who had not received regular competency evaluations. The error resulted in the resident being hospitalized for adverse reactions, including hypotension and hyponatremia. Review of staff files showed inconsistent or missing skills assessments for several CMAs, and the DON confirmed that annual competencies had not been completed consistently.
The facility failed to follow its abuse policy by not immediately reporting abuse allegations for two residents. One resident, with multiple diagnoses including schizophrenia, reported verbal abuse by an aide, while another resident with dementia and Alzheimer's Disease reported being physically mishandled. In both cases, the incidents were not reported to the OSDH within the required two-hour timeframe, and the DON was not promptly informed.
The facility failed to report allegations of abuse involving two residents to the OSDH within the required two-hour timeframe. One resident reported verbal abuse, while another reported physical mishandling. Both incidents were documented, but the state incident reports were faxed several hours later, exceeding the mandated reporting period. The DON confirmed the delay in reporting.
The facility failed to conduct thorough abuse investigations for two residents. One resident reported verbal abuse by an aide, while another reported being physically mishandled. Both investigations lacked critical documentation, including resident statements and details of interviews. The DON acknowledged the absence of documented interviews, as the investigations were conducted together due to the incidents involving the same staff member.
A CNA recorded and posted a video on social media mocking and verbally abusing a resident with Alzheimer's and other disorders. The resident appeared to be crying while the CNA laughed. The DON terminated the CNA and reported the incident to the state.
The facility failed to post the required staffing information in an easily accessible manner for residents and visitors. The information was placed on a bulletin board six feet from the floor, making it difficult to read, and did not include the census or staffing hours for each employee. The DON was unaware of the regulations regarding the accessibility of posted staffing information.
The facility failed to store food in accordance with professional standards, affecting all 53 residents who received meals from the kitchen. Observations included an unlocked ice machine, an uncovered trash can, improperly stored and dated food items, and unsanitary conditions in the ice machine. The Dietary Manager acknowledged these issues and admitted to lapses in hand hygiene and food safety practices.
The facility failed to follow infection control guidelines, with staff not performing hand hygiene during meal assistance and wound care, and the IP testing a resident for COVID-19 without proper PPE in a communal area.
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 13 employees. Payroll records confirmed these employees were permitted to work without the required checks, and the BOM and administrator were unaware of this oversight until the survey.
The facility failed to ensure residents were fully assessed for the use of side rails for four of the 35 sampled residents. Observations revealed that residents with various diagnoses were using bed rails without proper assessments documented in their EHRs. The DON acknowledged the lack of documentation and stated that bed rail assessments would start being documented routinely.
The facility failed to ensure DNR forms were complete and legal for two residents. One resident's DNR form lacked the required two witnesses, and another resident's DNR form was not dated. The DON confirmed these deficiencies during interviews.
The facility failed to ensure accurate MDS assessments for four residents, leading to incorrect documentation of medical conditions and care needs. Issues included misreporting anticoagulant use, hearing ability, fall incidents, and urinary incontinence.
The facility failed to notify OHCA of a resident with serious mental illness who stayed long-term. The resident had diagnoses including generalized anxiety disorder, major depressive disorder, and schizophrenia. A PASRR I screening indicated no need for PASRR II for a short stay, but the resident's care plan and annual assessment were inconsistent. The DON acknowledged the oversight.
The facility failed to develop a comprehensive care plan for a resident experiencing weight loss, despite physician's orders for nutritional supplements and health shakes. The MDS coordinator confirmed the absence of a care plan addressing the resident's weight loss.
The facility failed to ensure residents were not catheterized unless required by a clinical condition and did not assess the continued need for an indwelling urinary catheter for two residents. One resident had a catheter placed for isolation purposes due to ESBL, which is not a proper diagnosis for catheter use. Another resident had a catheter placed due to ESBL and E. coli in their urine, with no physician's orders for catheter care or changing the catheter. The infection preventionist confirmed there was no policy for catheterizing residents with UTIs.
The facility failed to ensure the physician documented a rationale on a consultant pharmacist recommendation for a resident with multiple diagnoses, including CHF and Alzheimer's. The MRR policy also lacked timeframes for the process steps, as confirmed by the DON.
The facility failed to ensure that a resident did not receive psychotropic medication unless for a specific diagnosed condition. The resident was prescribed Seroquel for Alzheimer's Disease, but a medication review later marked the diagnosis as mood disorder. The DON acknowledged the need for prompt diagnosis changes.
The facility failed to provide consistent dietitian services for a resident with multiple health issues, despite recommendations for nutritional supplements and health shakes. The last dietitian visit was in August 2023, and the care plan lacked documentation of these recommendations.
The facility failed to develop and implement a QAPI plan to identify and address problems. The QAPI meetings were sporadic, with the last meeting in September 2023. The DON confirmed that there was no formal policy and procedure for QAPI, and meetings were not held regularly. The DON mentioned that a QAPI meeting would likely be held after the current month due to a COVID outbreak in February.
The facility failed to ensure that the QAA committee met at least quarterly, with the last documented meeting in September 2023. The DON confirmed that meetings were not held regularly and were only convened to address specific issues. A QAA meeting was anticipated due to a recent COVID outbreak.
Failure to Prevent and Monitor Sexual Abuse Among Residents
Penalty
Summary
The facility failed to adequately monitor and prevent sexual abuse involving a resident with severe cognitive impairment and behavioral disturbances. The resident, diagnosed with unspecified dementia and severe cognitive impairment, was repeatedly found in situations with another resident where inappropriate sexual behaviors were observed or alleged. Documentation shows that the resident was found in another resident's room, with both individuals on the bed and one resident's pants unzipped. There were also multiple reports of the resident making sexually suggestive gestures and engaging in inappropriate physical contact, such as holding hands and touching another resident's upper body. Staff and nursing notes indicate that these incidents were recurrent, with the resident being redirected or separated from others on several occasions. Despite these interventions, the inappropriate behaviors continued, and there were lapses in the implementation and documentation of one-on-one supervision. The facility's policy required thorough investigation and prevention of abuse, but the records show inconsistent monitoring and supervision, with periods where one-on-one documentation was missing for several days, even after the DON had indicated that such supervision was necessary until the behavior was resolved. Interviews with staff confirmed that the resident's behaviors were known and that supervision was inconsistently applied, with activity staff and nurses rotating responsibility for monitoring. The DON determined when to start and stop one-on-one supervision, but there was no clear or consistent protocol followed, and the resident continued to interact primarily with cognitively impaired residents. The failure to maintain consistent supervision and prevent further incidents resulted in the facility not protecting residents from sexual abuse as required by policy.
Failure to Provide Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide copies of its bed-hold policy to residents at the time of transfer to the hospital, as required. For one resident with renal failure, hypertension, and severe cognitive impairment (BIMS score of 2), a significant change assessment was completed in mid-April. A health status note documented that this resident was sent to the emergency room for evaluation, with the power of attorney notified and an ambulance called. However, there was no documentation that a copy of the facility’s bed-hold policy was provided at the time of this hospital transfer. In an interview, an LPN stated they did not give a copy of the bed-hold policy to residents when they were sent to the hospital. The DON stated that residents were given a copy of the bed-hold policy upon admission but not at the time of transfer to the hospital. For a second resident, a nurse’s progress note showed the resident was sent to the emergency room and admitted to the hospital for acute cystitis, with no documentation that the resident received a copy of the facility bed-hold policy at the time of transfer. The resident was later readmitted to the facility, and a subsequent quarterly assessment showed moderate cognitive impairment (BIMS score of 10). In interviews, the LPN again stated they did not provide residents with copies of the bed-hold policy when residents were sent to the hospital. The DON confirmed that the facility normally did not hand out the bed-hold policy after the initial admission and indicated that this resident had likely been informed about the bed-hold policy many years earlier, with the bed held since that time.
Failure to Limit and Re-Evaluate PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders were limited to 14 days and then re-evaluated, as required by its own pharmacy policy. The undated Pharmacy Service Policy stated that PRN orders for psychotropic drugs must be limited to 14 days unless the attending physician or prescribing practitioner documented a rationale in the medical record and indicated a specific duration for extending the order. For one resident, a physician’s order dated 02/22/25 directed administration of 0.5 mg Ativan by mouth every 12 hours as needed for anxiety, but the order did not include an end date. A Pharmaceutical Consultant Report dated 03/28/25 identified this resident as receiving an as-needed psychoactive medication that could be considered a chemical restraint and reiterated that any extension beyond 14 days required documented rationale and a specific duration. In response to the consultant’s review, the physician indicated that the report was reviewed and that no changes were desired, preferring the order to remain PRN unless directed otherwise in the future, but did not provide any handwritten rationale or specify a duration for the extended PRN order. A quarterly assessment dated 06/05/25 documented that the resident had anxiety disorder and depression, a BIMS score of 15 indicating intact cognition, and was receiving an antianxiety medication. During interviews, an LPN and the DON both stated that PRN antianxiety and psychotropic medications should only be ordered for two weeks unless a physician provided a rationale and duration, confirming that the standing PRN Ativan order without an end date or documented rationale was inconsistent with facility policy and regulatory expectations.
Unlabeled Enteral Tube Feeding Bag for Resident on Continuous Feeding
Penalty
Summary
The deficiency involves the facility’s failure to properly label an enteral tube feeding bag for a resident receiving continuous tube feeding. The DON identified one resident who received enteral nutrition via continuous pump. On two separate observations, the resident’s tube feeding was running at 50 ml/hr with no label on the feeding bag. During interviews, a certified medication aide stated they could not determine by looking at the bag which resident it was intended for or what time it was hung and acknowledged it should have had a label. An LPN also stated they could not identify which resident the tube feeding was for because the bag was not labeled and did not know why it was unlabeled. The DON confirmed they could not tell the time or date the bag was hung or which resident it was intended for due to the lack of a label and stated the bag should have been labeled, but did not know why it was not.
Failure to Ensure CMA Competency Leads to Medication Error and Hospitalization
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) were properly trained and competent to administer medications as ordered, resulting in a significant medication error. On one occasion, a CMA reported to a registered nurse that they may have given the wrong medications to a resident. Review of camera footage confirmed that the resident was administered another resident's medications. The resident, who had diagnoses including aphasia, vascular dementia, and cerebrovascular disease, was sent to the emergency room after the error was discovered. The resident was later admitted to the intensive care unit for adverse reactions, including hypotension and hyponatremia, after receiving multiple medications not prescribed to them. The resident involved had a care plan indicating a risk for hypotension and a recent assessment showing severe cognitive impairment. The medications administered in error included a diuretic, blood pressure medication, antidepressant, antianxiety medication, pain medication, and antiparkinsonian medication. The incident note documented a critically low blood pressure at the time paramedics arrived, and hospital records confirmed the resident required interventions to stabilize their blood pressure due to the medication error. Review of employee files revealed that several CMAs had not received regular skills evaluations or competency check-offs since their initial hire, with some files lacking any evidence of annual competency assessments. Interviews with the DON and CMAs confirmed that annual competencies had not been consistently completed for at least two years, and the DON acknowledged that medication administration was not routinely observed. Additionally, a similar medication error involving the same resident and another CMA had occurred previously, resulting in hospitalization, but no substantial interventions were implemented at that time.
Failure to Ensure CMA Competency Leads to Significant Medication Error
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) were adequately trained and competent to administer medications as ordered, resulting in a significant medication error. On one occasion, a CMA reported to an RN that they may have given the wrong medications to a resident. Review of camera footage confirmed that the resident was administered another resident's medications. The resident, who had diagnoses including aphasia, vascular dementia, and cerebrovascular disease, was at risk for hypotension and had a severely impaired cognitive function as indicated by a BIMS score of 3. Following the medication error, the resident was sent to the emergency room after being found with a blood pressure of 146/21. The resident was admitted to the intensive care unit for adverse reaction to medication, hypotension, and hyponatremia. Documentation showed the resident had been given multiple medications not prescribed to them, including a diuretic, blood pressure medication, antidepressant, antianxiety medication, pain medication, and antiparkinsonian medication. The resident required interventions to stabilize their blood pressure while the effects of the incorrect medications wore off. Review of employee files revealed that several CMAs had not received regular skills evaluations or competency check-offs since their hire or for extended periods, with some having no record of annual skills assessments. The DON acknowledged that annual CMA competencies had not been completed consistently for the last two years and that medication administration was not routinely observed. It was also noted that a similar medication error involving the same resident had occurred previously, resulting in hospitalization, but only limited education was provided to the involved CMA and no further interventions were implemented.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy by not immediately reporting allegations of abuse for two residents. The policy requires that all alleged violations and abuse be reported to the charge nurse, who must then notify the Administrator and Director of Nursing (DON) immediately, and report to the appropriate agencies within a two-hour timeline. In the case of the first resident, who had diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia, an incident was reported where the resident was verbally abused by an aide. Although the incident was reported to the Assistant Director of Nursing (ADON) and the DON was investigating, the state incident report was not faxed to the Oklahoma State Department of Health (OSDH) until several hours later. For the second resident, who had diagnoses including a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease, an incident occurred where the resident reported being physically mishandled by a staff member. The DON was not made aware of this incident until later in the afternoon, and the state incident report was also delayed in being faxed to the OSDH. The DON confirmed that the staff did not notify them or the administrator of the allegations of abuse in a timely manner, and neither incident was reported to the OSDH within the required two-hour timeframe as per the facility's policy.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe. The facility's abuse policy mandates that all alleged violations and/or abuse reported to the charge nurse must be assessed and reported to the appropriate agencies within two hours. In the first incident, a resident with diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia reported verbal abuse by an aide. The incident was documented at 3:15 p.m., but the state incident report was not faxed to OSDH until 7:36 p.m., exceeding the two-hour requirement. In the second incident, a resident with a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease reported being physically mishandled by a staff member, causing back pain. This incident was documented at 9:30 a.m., but the state incident report was not faxed until 7:38 p.m. The Director of Nursing (DON) acknowledged during an interview that neither incident was reported within the required timeframe, indicating a failure to adhere to the facility's abuse reporting policy.
Incomplete Abuse Investigations for Two Residents
Penalty
Summary
The facility failed to conduct a thorough abuse investigation for two residents who were reviewed for abuse. The first resident, who had diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia, reported that an aide verbally abused them using offensive language. The incident was reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who initiated an investigation. However, the investigation lacked critical documentation, including a statement from the resident, statements from all involved staff, and details about the residents interviewed. Additionally, there was no documentation of the date, time, or number of residents interviewed. The second resident, with diagnoses including a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease, reported being physically mishandled by a staff member, which caused them pain. The incident was reported, and the DON was aware and investigating. Similar to the first case, the investigation was incomplete, lacking documentation of resident interviews and statements from all involved staff. The DON stated that the investigations for both residents were conducted together due to the incidents involving the same staff member and occurring simultaneously, but acknowledged the absence of documented interviews.
Resident Abuse Incident Involving Social Media
Penalty
Summary
The facility failed to ensure a resident was free from abuse. A CNA recorded a video of a resident with Alzheimer's disorder, dementia, depression disorder, and anxiety disorder, mocking and verbally abusing the resident while they were sitting in their wheelchair. The resident appeared to be crying, and the CNA was laughing at them. This video was then posted on social media, which was discovered by the Director of Nursing (DON) shortly after it was posted. The DON immediately called everyone involved into their office and terminated the CNA responsible for the video. Another CNA who was aware of the recording but did not report it was given a written warning. The incident was reported to the state, and the video was retained for investigation purposes. The facility conducted an in-service training on abuse and reporting abuse for all employees following the incident.
Failure to Post Accessible Staffing Information
Penalty
Summary
The facility failed to post the required staffing information in a manner easily accessible to residents and visitors. On 03/06/24 at 10:00 a.m., the surveyor was unable to locate the posted staffing information. An RN indicated that the information was on a bulletin board on the 200 Hall outside the dining room entrance. The posted staffing information was observed on an 8.5 x 11 piece of copy paper pinned to a bulletin board approximately six feet from the floor, making it difficult to read unless directly in front of the board and looking up ten inches. Additionally, the posted staffing information did not document the census or staffing hours for each employee. The information remained in the same location and without the required details for the remainder of the survey. On 03/08/24 at 10:00 a.m., the DON questioned why residents couldn't tilt their heads up to read the information and was informed of the regulations regarding posted staffing requirements and accessibility for residents and visitors.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, affecting all 53 residents who received meals from the kitchen. During an observation, the ice machine in the dining room was found unlocked, and a large trash can by the hand washing sink was missing its lid, which was found on the floor behind the trash can. Additionally, the freezer contained bags of French fries and onion rings that were open to the air and not dated when they had been opened. The Dietary Manager (DM) acknowledged that these items should not be open to air and should be dated when opened. Further observations revealed that the ice machine had a brown/black substance on a clean cloth used to wipe it, and the DM admitted they did not know what the substance was. The DM also stated that the ice machine should be locked when not in use, but staff often failed to lock it. Additionally, the DM entered the kitchen without washing their hands and expressed concerns about contaminating their hands by touching the trash can lid. The DM mentioned that a surveyor from the previous year had advised that the trash only needed to be covered when being transported. The DM confirmed that staff entering the kitchen should wash their hands.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff followed infection control guidelines, leading to potential spread of communicable diseases. Observations revealed that a CNA assisting residents with eating did not perform hand hygiene after scratching their face, touching their clothing, or handling dirty dishes. Another CNA also failed to perform hand hygiene between assisting different residents. The Infection Preventionist (IP) confirmed that staff should use hand hygiene between residents and after touching something dirty while assisting residents to eat. Additionally, a registered nurse (RN) did not follow proper hand hygiene protocols during wound care. The RN washed their hands before care and applied gloves but did not perform hand hygiene after cleaning a resident who had a bowel movement. The RN also failed to perform hand hygiene between removing the old dressing, cleaning the wound, and applying skin prep. Furthermore, the IP was observed testing a resident for COVID-19 in a communal activity room without proper personal protective equipment (PPE), which could have potentially spread the infection to others in the facility.
Failure to Obtain Criminal Background Checks for Employees
Penalty
Summary
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 13 of 74 employees hired between 2016 and 2024. The facility's Abuse Prevention Policy mandates that candidates for employment be screened for a potential history of abuse, neglect, or mistreatment before employment, including obtaining criminal background checks. However, the facility did not have criminal background checks for 13 employees, including CNAs, CMAs, and a laundry staff member. Payroll records confirmed that these employees were permitted to work without the required background checks, and the BOM and administrator were unaware of this oversight until it was brought to their attention during the survey. The BOM reported that criminal background checks could not be done for some employees because they had not been fingerprinted. Additionally, the BOM incorrectly believed that if an employee returned within three years of separation, a new background check was not required. The DON and administrator were also unaware of the lack of background checks for these employees. The facility's failure to adhere to its own abuse prevention policy and ensure that all employees had completed criminal background checks upon hire led to this deficiency.
Failure to Assess Bed Rail Use for Residents
Penalty
Summary
The facility failed to ensure residents were fully assessed for the use of side rails for four of the 35 sampled residents. Resident #11, who had diagnoses including CHF, chronic kidney disease, and Alzheimer's Disease, was observed multiple times with bed rails up on both sides of the bed. The resident's EHR did not contain bed rail assessments, and the LPN confirmed that bed rail assessments had only recently started without a proper template. The resident's POA was informed of the risks but still wanted the bed rails to prevent the resident from trying to get out of bed, despite the resident not having the strength to do so. Resident #22, diagnosed with generalized anxiety disorder, major depressive disorder, diabetes mellitus with diabetic neuropathy, CHF, and schizophrenia, was also observed using bed rails without proper assessments documented in the EHR. The resident stated they used the bed rails for positioning and had never fallen out of bed. The LPN confirmed that bed rail assessments for this resident had not been completed. Resident #42, with diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia, was observed with bed rails up and a bed alarm in place. The EHR did not contain assessments for bed rails, although a waiver was signed by the resident's POA. Similarly, Resident #45, with diagnoses including unspecified osteoarthritis, COPD, and primary osteoarthritis of both shoulders, was observed using bed rails and an air mattress without documented assessments. The DON stated that nurses assess the side rails daily but do not document these assessments in the chart, and they would start utilizing a bed rail assessment form routinely.
Incomplete and Illegal DNR Forms
Penalty
Summary
The facility failed to ensure DNR forms were complete and legal for two residents. One resident with diagnoses including CHF, chronic kidney disease, and Alzheimer's Disease had a DNR form signed by the resident's POA but lacked the required two witnesses. Another resident with diagnoses including major depressive disorder, anxiety disorder, and osteoarthritis had a DNR form signed by the POA but it was not dated. The DON confirmed these deficiencies during interviews.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of MDS assessments for four residents. One resident with a history of deep vein thrombosis was incorrectly documented as not being on an anticoagulant, despite physician orders and care plans indicating otherwise. Another resident, who was blind and hard of hearing, was inaccurately assessed as having adequate hearing. Additionally, a resident who experienced two falls, one resulting in a subdural hematoma, had these incidents omitted from their significant change assessment. Lastly, a resident with a Foley catheter due to urinary retention was incorrectly documented as always incontinent of urine, despite observations and statements confirming the presence of the catheter. These inaccuracies in MDS assessments were identified through observations, record reviews, and interviews with staff and family members. The discrepancies highlight a failure in the facility's assessment process, leading to incorrect documentation of residents' medical conditions and care needs. This failure could potentially impact the quality of care provided to the residents, as accurate assessments are crucial for developing appropriate care plans and interventions.
Failure to Notify OHCA of Resident with Serious Mental Illness
Penalty
Summary
The facility failed to notify the Oklahoma Health Care Authority (OHCA) of a resident with a serious mental illness who stayed in the facility long-term. The resident had diagnoses including generalized anxiety disorder, major depressive disorder, and schizophrenia. A PASRR I screening dated 06/26/14 indicated the resident had a serious mental illness, and it was documented that a PASRR level II was not required for a short stay for therapy. However, the resident's care plan, revised 08/26/22, noted ongoing concerns related to schizophrenia and the use of psychotropic medications. An annual assessment dated 09/19/23 incorrectly documented that the resident was not considered to have a serious mental illness. The Director of Nursing (DON) later acknowledged that another staff member failed to conduct a new PASRR I when the resident stayed long-term in the facility.
Failure to Develop Comprehensive Care Plan for Weight Loss
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident experiencing weight loss. The resident had diagnoses including diabetes mellitus type 2, abdominal hernia, and major depressive disorder. Physician's orders were documented for nutritional supplements, health shakes, and protein powder to address the resident's weight loss. Despite these orders, a care plan dated 02/04/24 did not document the resident's weight loss. The MDS coordinator confirmed on 03/07/24 that there was no care plan for the resident's weight loss, indicating a lapse in the facility's care planning process.
Improper Use of Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure residents were not catheterized unless required by a clinical condition and did not assess the continued need for an indwelling urinary catheter for two residents. Resident #29 was admitted with multiple diagnoses including stage 3 kidney disease and dementia. Despite having a urinary tract infection with ESBL, there was no documentation of a catheter in the care plan. The DON acknowledged that the catheter was used for isolation purposes, which is not a proper diagnosis for catheter use. The care plan was not updated to reflect the presence of the catheter, and the DON admitted that ESBL was not a valid reason for catheterization. Resident #25, diagnosed with chronic kidney disease stage 4 and dementia, had a 16 Fr indwelling urinary catheter placed due to ESBL and E. coli in their urine. There were no physician's orders for catheter care or changing the catheter. The infection preventionist confirmed there was no policy or protocol for catheterizing residents with urinary tract infections and admitted that catheterizing for a UTI likely does not meet criteria. The DON stated that catheters were used for residents who were difficult to keep in their rooms for isolation, but acknowledged that ESBL was not a proper diagnosis for catheter use.
Failure to Document Rationale for Medication Regimen Review
Penalty
Summary
The facility failed to ensure the physician documented a rationale on a consultant pharmacist recommendation for a resident whose medications were reviewed. The resident had diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia. A medication regimen review (MRR) requested a reduction in several medications, but the physician documented to continue the current use of medications without providing a rationale. Additionally, the facility's MRR policy did not contain timeframes for the steps in the MRR process. The Director of Nursing (DON) confirmed that the policy lacked timeframes and stated that physicians usually document their decisions on the MRRs.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medication unless for a specific diagnosed condition. This was identified for one of five residents reviewed for unnecessary medication. The facility's policy stated that drug regimens should be free from unnecessary drugs and that psychotropic medications should only be used when necessary to treat a specific condition documented in the clinical record. A resident with diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia was prescribed Seroquel 25mg twice a day for Alzheimer's Disease. A medication review requested an appropriate diagnosis for the use of Seroquel, and the physician later marked the diagnosis as mood disorder. The resident's care plan documented the use of Seroquel for Alzheimer's Disease. The Director of Nursing acknowledged that the diagnosis should be changed promptly upon receiving the medication review request from the physician.
Inconsistent Dietitian Services and Documentation
Penalty
Summary
The facility failed to provide consistent services from a registered dietitian for one of the two residents reviewed for nutrition. The resident had diagnoses of diabetes mellitus type 2, abdominal hernia, and major depressive disorder. Despite multiple recommendations from a registered dietitian for nutritional supplements and health shakes, the facility did not document these recommendations in the resident's care plan. Additionally, the facility's business manager stated that the last visit from a registered dietitian was in August 2023, despite the facility contracting for monthly visits. This inconsistency in dietitian services and lack of documentation led to the deficiency.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) plan to identify and address problems within the facility. Record review and interviews revealed that the facility did not have a policy and procedure for QAPI. The QAPI meetings were held sporadically, with the last meeting occurring in September 2023. On March 11, 2024, the Director of Nursing (DON) confirmed that QAPI meetings were not implemented regularly and that there was no formal policy and procedure to follow for QAPI. The DON stated that when issues arose, the administrator, DON, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) coordinator, and Infection Preventionist would meet to address the problems. The DON also mentioned that a QAPI meeting would likely be held after the current month due to a COVID outbreak in February.
Failure to Hold Quarterly QAA Committee Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly, as required. A review of the QAA committee meetings revealed that the last documented meeting was in September 2023. There was no documentation of meetings in October, November, and December 2023, nor in January or February 2024. The Director of Nursing (DON) confirmed that QAA meetings were not held regularly and stated that meetings were only convened when specific problems needed to be addressed. The DON mentioned that a QAA meeting would likely be held after the current month due to a COVID outbreak in February.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 41 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pocola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fianna Hills Nursing And Rehabilitation Center | 4.6 mi | ★★★★★ | 1 | 0 |
| Brooken Hill Health And Rehab, Llc | 5.1 mi | ★★★★★ | 10 | 0 |
| The Blossoms At Fort Smith Rehab & Nursing Center | 5.5 mi | ★★★★★ | 9 | 0 |
| Riverside Health Services | 6.7 mi | ★★★★★ | 6 | 0 |
| Covington Court Health And Rehabilitation Center | 6.9 mi | ★★★★★ | 5 | 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.