Above 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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ponca City Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Use PPE During Catheter Care: A CNA provided catheter and incontinent care to a resident with an indwelling urinary catheter and moderate cognitive impairment while wearing gloves but did not change them between dirty and clean tasks, did not wear a gown, and did not wash or sanitize hands after care. The resident's care plan and MD order required Enhanced Barrier Precautions with gown and gloves during high-contact care, and the IP stated gown and gloves were to be worn during urinary catheter care.
Failure to provide bedside fluids for a resident reviewed for hydration. A cognitively intact resident who was independent with eating and drinking reported drinking from the bathroom sink because staff did not pass ice or water and they did not want to bother staff. Surveyors observed no fluids in the room at one point, and staff gave conflicting statements about whether a fluid cup was present. The DON stated staff were expected to offer fresh ice and water during rounds, meals, and resident assistance, and the resident was not on a fluid restriction.
A resident with intact cognition did not receive individualized in-room activities as preferred, due to a lack of documentation for April and May. The activities director acknowledged the absence of records, possibly due to a failure to save and lock the information in the system.
A facility failed to provide necessary restorative care for a resident with contractures, despite the resident's desire for such care and the facility's policy requiring it. The resident, with diagnoses including Guillain-Barre syndrome, had impairments in both upper and lower extremities but was not receiving restorative services due to Medicaid eligibility issues. Staff confirmed the resident's condition and need for assistance, and the DON admitted the resident was a candidate for care but lacked documentation of care or refusal.
A facility failed to implement a physician's order for a gradual dose reduction of mirtazapine for a resident with Alzheimer's and depression. Despite a pharmacist's recommendation and a physician's signed order to reduce the dose from 30 mg to 15 mg, the resident continued to receive the higher dose. The DON confirmed that the facility's policy was not followed, resulting in the oversight.
A resident with multiple medical conditions was found without a proper call light system in their room. Instead, a doorbell apparatus was used, which required the resident to repeatedly push the button for assistance. The DON acknowledged that this system was inadequate for emergencies.
Failure to Use PPE During Catheter Care
Penalty
Summary
The facility failed to ensure staff used personal protective equipment during catheter care for one resident with an indwelling urinary catheter. Resident #3 was observed on 07/01/26 with an indwelling urinary catheter in place while seated on the toilet. CNA #7 wore gloves to drain the catheter tubing, placed the urine-filled container on the edge of the sink, wiped the resident's buttock, and then used the same soiled gloves to place a clean brief and pull up the resident's pants. CNA #7 then transferred the resident to a recliner and combed the resident's hair before removing the gloves and discarding them. CNA #7 was not observed changing gloves between clean and dirty tasks, was not observed wearing a gown, and was not observed washing or sanitizing hands after providing incontinent care. Resident #3 had a quarterly assessment showing a BIMS score of 9, indicating moderate cognitive impairment, and the resident had an indwelling urinary catheter. The care plan identified the catheter and included Enhanced Barrier Precautions requiring a gown and gloves, and a physician's order also required Enhanced Barrier Precautions with gown and gloves during high-contact resident care activity every shift. The facility's Catheter Care policy stated that personal protective equipment, including gowns and gloves, should be assembled as needed. During interviews, CNA #7 stated they were supposed to change toilet tissues after each wipe and change gloves, and the IP stated a gown and gloves were to be worn during urinary catheter care.
Failure to Provide Bedside Fluids
Penalty
Summary
The facility failed to ensure a resident had fluids at bedside for 1 of 3 sampled residents reviewed for hydration. Resident #30 had a BIMS score of 14 on a 5-day scheduled assessment dated 04/08/26, indicating intact cognition for daily decision making, and was independent in eating and drinking. On 06/30/26 at 9:50 a.m., no fluids were observed in the resident’s room, and the resident stated they drank from the bathroom sink because they did not want to bother staff and that staff did not pass ice or water. On 07/02/26, the resident was observed holding a small clear plastic cup with water. CNA #2 stated they were to pass ice and water during hourly rounds and at 10:00 a.m. and 2:00 p.m., while CNA #4 stated the resident had a maroon cup in the room for fluids, which CNA #2 said they did not see. The DON stated staff were to offer fresh ice and water at 10:00 a.m., 2:00 p.m., 8:00 p.m., during meals, and with all resident assistance, and stated it was not acceptable for residents to drink from the bathroom sink; the resident was not on a fluid restriction.
Failure to Provide Individualized In-Room Activities
Penalty
Summary
The facility failed to provide individualized in-room activities for a resident who preferred such activities, as documented in the resident's care plan. The resident, who had intact cognition, reported not receiving one-to-one activities in their room during April and May 2024, expressing a belief that they were not provided due to potential extra charges. The activities director confirmed the absence of documentation for these months in the resident's medical record, attributing it to a possible failure to save and lock the information in the system. This deficiency was identified during a review of the resident's medical record and interviews with the resident and the activities director.
Failure to Provide Restorative Care for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary restorative care for a resident with contractures, leading to a deficiency in care. Resident #46, who was admitted with diagnoses including esophagitis and Guillain-Barre syndrome, had documented range of motion impairments in both upper and lower extremities. Despite the facility's policy stating that residents should receive restorative nursing care as needed, there was no documentation indicating that Resident #46 was receiving such services. The resident expressed a desire for restorative care but was reportedly not receiving it due to Medicaid eligibility issues. Observations and interviews with staff revealed that Resident #46 had contractures in both hands and legs and required assistance with transfers. The DON acknowledged that Resident #46 was a candidate for restorative care and should have been receiving it, but there was no documentation of either the provision of care or a refusal by the resident. This lack of action and documentation led to the facility's failure to provide appropriate treatment and services to address the resident's contractures, as required by their own policy.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a physician order was completed for a gradual dose reduction for a resident reviewed for unnecessary medications. The resident, who had diagnoses including Alzheimer's, depression, and cognitive communication deficit, was receiving mirtazapine (Remeron) 30 mg at bedtime. A Medication Regimen Review recommended by a pharmacist suggested reducing the mirtazapine dose to 15 mg at bedtime, and this recommendation was signed by a physician. However, the Medication Administration Record for the resident documented that the resident continued to receive the original 30 mg dose. The Director of Nursing (DON) confirmed that the facility's policy required the nurse who takes or notes the order to make changes in the resident's chart. Upon review, the DON acknowledged that the order to reduce the mirtazapine dose was not implemented as per the physician's signed order. This oversight indicates a failure in the facility's process for updating medication orders, leading to the resident continuing on a higher dose than recommended.
Inadequate Call System for Resident
Penalty
Summary
The facility failed to maintain an adequate call light system for a resident, leading to a deficiency. The resident, who had a history of atherosclerotic heart disease, pulmonary embolism, type 2 diabetes, syncope, and age-related physical debility, was observed without a call light connected to the wall system in their room. Instead, a two-part doorbell apparatus was used as a substitute call system. This apparatus was zip-tied to the positioning rail of the resident's bed, and the base was plugged into an outlet at the nurses' station at the end of the hall. The resident could only access the push button part of the apparatus while in bed. During a test of the call system, it was observed that the doorbell would chime only once when pushed, requiring the resident to repeatedly push the button for multiple chimes. The Director of Nursing (DON) acknowledged that the call system in place would not be adequate if the resident experienced a fall or a serious medical event, such as cardiac or respiratory distress, or a hypoglycemic or hyperglycemic event, and was unable to repeatedly push the call button.
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What surveyors actually found near you
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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 Ponca City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shawn Manor Nursing Home | 2.5 mi | ★★★★★ | 0 | 0 |
| Bradbury Commons | 3.5 mi | ★★★★★ | 0 | 0 |
| Willow Haven Nursing Home | 11.4 mi | — | 0 | 0 |
| Hillcrest Manor Nursing Center | 11.6 mi | ★★★★★ | 0 | 0 |
| Fairfax Behavioral Health & Memory Care Community | 23.9 mi | ★★★★★ | 4 | 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 October 2026) and official state health department websites.