Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 Sherwood Manor Nursing Home during CMS and state inspections, most recent first.
Staff failed to follow infection prevention practices in multiple areas. An LPN provided nail care to a resident on EBP without a gown, despite the resident having a feeding tube and needing assistance with ADLs. The same LPN did not disinfect a multi-use glucometer between blood glucose checks for two residents, instead using an alcohol wipe on the residents' fingers. The facility also had not completed N-95 fit testing for staff, and the DON and ADON/IP stated fit testing had not been done for years.
Failure to Maintain Privacy During Incontinence Care: A cognitively impaired, non-verbal resident with Rett's syndrome and functional quadriplegia received incontinence care without the privacy curtain pulled or the room door closed. The CNA provided care while the resident was visible to others, and the ADON, DON, and ADM stated the resident should have been kept private and received dignified care.
Two residents receiving Medicare Part A skilled services had incomplete SNFABNs. One resident had moderate cognitive impairment and the other had intact cognition, but both notices stated Medicare may not pay because of refusing to participate and not making progress without clearly identifying the covered care or, for one resident, the estimated cost. The SS Coordinator said the form was used with admission or readmission paperwork and that the cost was left blank because it was unknown.
Wheelchair Not Maintained in Safe Operating Condition: A resident with hemiplegia, muscle weakness, and severe cognitive impairment was observed using a wheelchair with a missing armrest on one side and peeling material on the other. The maintenance log had no report of the damage, and staff, including a CNA, LPN, DON, Maintenance Supervisor, and Administrator, stated the issue had not been reported for repair.
MDS medication coding was inaccurate for three residents. One resident with heart failure was coded for insulin even though the active order was for Mounjaro, another resident with Parkinson’s disease was coded for an antipsychotic despite having an anticonvulsant order for divalproex sodium and no antipsychotic order, and a third resident with type 2 diabetes was coded for insulin even though the active order was for Ozempic. The MDS Coordinator acknowledged the coding errors, and the DON and ADM stated they expected MDS assessments to be complete and accurate.
A resident with Rett's syndrome and functional quadriplegia received PEG tube feedings that did not match the physician's order. Staff observed the tube feeding running as Nutren 1.5 instead of the ordered Isosource 1.5, and one LPN said he noticed the wrong formula overnight, texted the ADON, then later changed it without notifying the provider or RD. Other staff confirmed nurses were expected to verify the formula against the order, but one LPN had not checked the product being infused.
Medication Error Rate Exceeded Allowed Threshold: An LPN administered insulin to two residents without priming the insulin pens or performing the required safety test before each injection. One resident had type 2 DM with diabetic neuropathy and severe cognitive impairment, and the other had type 2 DM with intact cognition. Manufacturer instructions for Lantus and Novolog required priming before administration, and the pharmacist and DON confirmed the expectation to prime the pens.
A CNA engaged in a verbal and physical altercation with a resident, including yelling, threatening, and throwing milk at the resident, resulting in a scratch on the resident's forehead. The incident was witnessed by a CMA and an LPN, who attempted but failed to de-escalate the situation. The event was captured on video and reported to authorities, highlighting a failure to ensure residents are free from abuse.
A resident with schizoaffective disorder and bipolar type did not receive multiple consecutive doses of prescribed antipsychotic medications due to unavailability, with staff failing to notify the physician or follow facility policy. During this period, the resident exhibited worsening behavioral symptoms, including delusions, agitation, and threats, resulting in emergency room visits and psychiatric admission.
A resident with a diagnosis of schizoaffective disorder, bipolar type, was prescribed lithium and had a physician order for a lithium level lab test. The test was not requested or completed, as staff either did not see the option in the lab portal or mistakenly believed it would be included in a CBC. The DON was unaware of the omission and noted that audits to ensure labs were obtained had not been conducted recently.
A resident at risk for pressure ulcers was not properly assessed or monitored, resulting in a significant wound that went unreported to the physician for several days. The resident's family discovered the wound, which was emitting a foul odor, and the resident was eventually transferred to the hospital. The facility failed to follow protocols for skin integrity monitoring and communication.
The facility failed to secure chemicals in a shower room and nursing supply closet, leaving hazardous materials accessible. A resident with diabetes and renal disease was observed smoking unsupervised with a cigarette in their mouth, but the incident was not reported or documented. Additionally, a resident using bed rails lacked proper assessment and consent, as the facility did not routinely perform these evaluations.
The facility failed to maintain infection control during various procedures, including blood glucose monitoring, medication administration, wound care, and catheter care. An LPN did not wear gloves or disinfect the glucometer between uses, and CMAs handled medications with bare hands. Additionally, hand hygiene lapses were observed during wound and catheter care, with catheter bags touching the floor. The DON confirmed the need for proper handwashing and surface sanitization.
A facility failed to update a care plan for a resident with a stage four pressure ulcer. The resident's clinical record lacked documentation of the wound or wound care. The MDS coordinator admitted the omission, affecting one resident among 73 in the facility.
A resident with non-pressure wounds on their toes received unauthorized Betadine treatment from an LPN without obtaining physician orders. The LPN failed to notify the wound physician or document the new wounds, assuming the treatment would be ordered. The DON confirmed that nurses must obtain physician orders for wound treatments, which was not done in this case.
A resident with end-stage renal disease and cardiac issues did not have daily weights recorded as ordered by the physician. The facility's failure was due to unclear responsibilities between the restorative aide, charge nurse, and MDS coordinator, resulting in weights being recorded only 19 times out of 35 opportunities.
A facility failed to administer enteral formula as ordered for a resident with a gastrostomy. The resident was prescribed Nutren 1.5 at 60 ml/hr, but was observed receiving 50 ml/hr on multiple occasions. An LPN and the DON confirmed the discrepancy after reviewing the electronic clinical record and the formula label, but could not explain the error. Nurses were expected to verify the correct formula and rate on each shift.
A facility failed to conduct and document pre and post dialysis assessments for a resident with end-stage renal disease, despite having a care plan and physician's order for dialysis three times a week. Staff interviews revealed a lack of awareness and documentation of necessary assessments, as the facility was new to admitting residents requiring dialysis.
A facility failed to assess and inspect bed rails for entrapment risks for a resident who used them for repositioning. An LPN revealed that the last assessment was done months ago, despite monthly reassessment requirements. A maintenance worker stated they only addressed issues reported by staff and did not routinely check bedrails. The DON mentioned bed rails were used only upon resident request.
The facility failed to report abuse allegations to state agencies within the required time frame for two residents. One resident, with Parkinson's disease, had an abuse allegation against a CNA reported three days late. Another resident, with cognitive impairments, was involved in a possible exploitation incident reported two days late. The administrator was unaware of the two-hour reporting requirement.
A resident with Parkinson's disease and physical debility was left exposed during incontinent care when a CNA exited the room without using the privacy curtain. The LPN confirmed the exposure, as the privacy curtain was not utilized despite the door being closed.
A resident with Parkinson's Disease and physical debility experienced inadequate assessment and monitoring of a pressure ulcer due to inconsistent and incomplete documentation. The facility's policy requires detailed assessments, but records lacked necessary details about the ulcer's location and condition. The DON acknowledged the discrepancies and the need for proper monitoring.
Infection Prevention Failures With PPE, Glucometer Disinfection, and N-95 Fit Testing
Penalty
Summary
Staff failed to use enhanced barrier precautions while providing care to a resident with a feeding tube and severe cognitive impairment. Resident #63 was readmitted with diagnoses including Rett's syndrome and functional quadriplegia, had severe impairment in cognitive skills, and received 51% or more of nutritional intake via a feeding tube. During an observation, an LPN entered the resident's room to provide nail care without a gown and only donned gloves, even though nail care was identified in the facility policy as a high-contact activity requiring gown and glove use for enhanced barrier precautions. The resident was also observed with feces covering the left hand and attempting to place the hand in the hair during the encounter. Staff also failed to disinfect a multiuse glucometer between resident uses during blood glucose checks. Resident #2 had type 2 diabetes mellitus with diabetic neuropathy and severe cognitive impairment, and Resident #11 had type 2 diabetes mellitus without complications and intact cognition. During observations, the same LPN obtained blood glucose readings from both residents using the multi-use glucometer, but the glucometer was not disinfected before or after either use. The LPN placed an alcohol wipe on the glucometer but did not wipe the device with it, and instead used the wipe to clean the residents' fingers. The LPN stated she had been educated to disinfect the glucometer between residents but did not do so because she believed placing the wipe on the machine was sufficient. The facility also failed to conduct N-95 fit testing. The DON stated she had been trained to complete employee fit testing in 2023 but had not completed any N-95 fit testing since that training, and the ADON/IP stated she had not completed employee fit testing since 2022 or 2023. The DON further stated the facility had not had a policy in place for N-95 fit testing, while the Administrator stated she expected fit testing to be completed on hire and annually.
Failure to Maintain Privacy During Incontinence Care
Penalty
Summary
The facility failed to ensure a cognitively impaired resident received privacy during incontinence care. The resident was readmitted with diagnoses including Rett's syndrome and functional quadriplegia, and the quarterly MDS showed severe impairment in cognitive skills for daily decision-making, short- and long-term memory problems, non-verbal status, and that the resident was rarely or never understood and rarely or never understood others. The care plan stated the resident required total assistance with ADLs and staff needed to anticipate needs due to lack of speech. During an observation, a CNA provided incontinence care after the resident had a bowel movement, assembled supplies, donned a gown and gloves, cleaned the resident, and placed a clean brief on the resident. The CNA was not observed to pull the privacy curtain or shut the room door during the care, leaving the resident visible to staff, residents, or visitors who may pass the doorway. The ADON, DON, and Administrator each stated the resident's blinds, curtain, and door should have been closed to provide dignified care, and the ADON stated the resident did not receive a dignified experience when the care was provided without privacy.
Incomplete ABNs for Medicare Skilled Services
Penalty
Summary
The facility failed to provide an accurate Advance Beneficiary Notice of Non-Coverage (ABN) for 2 residents who were receiving Medicare Part A skilled services. Facility policy stated that when Medicare may not pay for otherwise covered skilled services, the resident or representative must be notified in writing of why the services may not be covered and of the resident’s potential liability for payment. For one resident, the record showed a history of type 2 diabetes mellitus, acute and chronic respiratory failure, and adult failure to thrive, with moderate cognitive impairment on MDS. The resident had a SNFABN signed that stated Medicare may not pay because of refusing to participate and not making progress, but it did not identify what care was to be provided or the estimated cost of the care. For the second resident, the record showed diagnoses including chronic atrial fibrillation, congestive heart failure, and chronic obstructive pulmonary disease, with intact cognition on MDS. The resident also had a SNFABN signed that stated Medicare may not pay because of refusing to participate and not making progress, but it listed the care that may not be paid for only as "Medicare" and did not include the estimated cost of the care. In interviews, the SS Coordinator stated the ABN was included in admission paperwork or given when a resident returned from the hospital on Medicare Part A, that the form had to be signed anytime a resident was on skilled Medicare services, and that the estimated cost was left blank because she had no way of knowing it. The DON stated she was not involved with the ABNs, and the Administrator stated the facility would review the process for providing ABNs.
Wheelchair Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure a wheelchair was maintained in safe operating condition for one resident who had hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, and severe cognitive impairment with a BIMS score of 3. The resident’s MDS indicated daily wheelchair use during the seven-day lookback period, and the care plan identified the resident as a fall risk related to a neuro-cognitive disorder, gait and balance instability, impulsiveness, and poor safety awareness. During observation, the resident was sitting in the wheelchair, which was missing the right armrest and had peeling plastic on the left armrest, exposing bare metal on one side. The facility’s maintenance log for the review period did not show any report of the wheelchair needing repairs or maintenance. Staff interviews indicated that broken equipment was supposed to be entered into the maintenance log and reported to nursing leadership and maintenance, but the CNA, LPN, DON, Maintenance Supervisor, and Administrator all stated they had not received a report about this wheelchair being damaged or missing parts, and the Maintenance Supervisor stated he had not known the armrests were broken and peeling.
MDS Medication Coding Errors
Penalty
Summary
The facility failed to ensure current MDS assessments were accurately coded for medications in Section N for 3 of 16 sampled residents. The report cited CMS LTC RAI 3.0 guidance stating that Section N is intended to record injections, insulin, and select medications received during the look-back period, and that insulin and high-risk drug classes must be coded according to the medication actually received and its pharmacological classification. Surveyors found that the MDSs for Residents #1, #9, and #29 did not match the residents’ active medication orders. Resident #1 was admitted with a history of heart failure and had a quarterly MDS with a BIMS score of 14, indicating intact cognition. The MDS coded the resident as receiving one day of insulin in the last 7 days, but the order summary showed no insulin order. Instead, the resident had an order for Mounjaro subcutaneous auto-injector 10 mg weekly for weight control. The MDS Coordinator stated Mounjaro was not insulin and should have been coded as an injection, and the DON and Administrator stated they expected staff to verify medications and code Section N correctly. Resident #9 was admitted with Parkinson’s disease with dyskinesia with fluctuations and had a significant change MDS with a BIMS score of 15. The MDS coded the resident as taking an antipsychotic and not taking an anticonvulsant, but the order summary showed divalproex sodium ER 500 mg at bedtime for depression and no antipsychotic order. Resident #29 was admitted with type 2 diabetes mellitus without complications and had an annual MDS with a BIMS score of 15. The MDS coded one day of insulin, but the order summary showed no insulin order and instead listed Ozempic 1 mg weekly for diabetes. The MDS Coordinator stated Ozempic had been incorrectly coded as insulin, and the DON and Administrator stated they expected MDS assessments to be complete and accurate.
Incorrect PEG Tube Formula Infused
Penalty
Summary
The facility failed to ensure a resident received PEG tube nutrition according to physician's orders. Resident #63, who had a history of Rett's syndrome and functional quadriplegia and was severely cognitively impaired, had an order for Isosource 1.5 cal at 40 mL per hour via PEG tube, with the feeding allowed to be off for up to four hours daily. The resident's care plan directed staff to administer tube feedings as ordered, and the TAR documented the ordered formula was infusing on two consecutive days. During observation, the resident's tube feeding was found running as Nutren 1.5 instead of the ordered Isosource 1.5, with the bag labeled accordingly and initialed by an LPN. Staff interviews showed one LPN did not verify the formula against the order, and another LPN stated he noticed the incorrect formula during the night, notified the ADON by text, and later changed it to the ordered formula after not receiving a return call. He stated he did not notify the provider or dietician and could not verify how much of the incorrect formula had infused. The RD stated the difference was the fiber content, and the ADON, DON, Administrator, and MD all acknowledged staff should verify the formula, with the MD stating he had no significant concern because the difference was only fiber content.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained at 5% or less. During medication administration observations, surveyors identified 3 medication errors out of 31 opportunities, affecting 2 of 4 residents reviewed, which resulted in a medication error rate of 9.68%. The deficiency was based on observation, interview, record review, facility policy review, and review of manufacturers’ instructions. For one resident with type 2 diabetes mellitus with diabetic neuropathy and severe cognitive impairment, an LPN administered 10 units of Lantus insulin without performing the safety test or priming the insulin pen. The resident’s order was for 10 units of Lantus subcutaneously daily. The manufacturer’s instructions for Lantus indicated that a safety test of 2 units should be performed before each injection. The pharmacist stated insulin pens should be primed with 2 units before each administration to remove air and ensure the resident did not miss 1 to 2 units of insulin. The LPN stated she had no knowledge of how to prime an insulin pen and did not understand the importance of completing that step. For another resident with type 2 diabetes mellitus without complications and intact cognition, an LPN administered 120 units of Lantus and 10 units of Novolog without performing the safety test or priming either insulin pen. The resident had active orders for Lantus in the morning and Novolog three times daily with meals. Manufacturer instructions for both insulin products required priming before administration. The LPN again stated she did not know how to prime an insulin pen, and the DON stated she expected the LPN to prime the insulin pen prior to administering each dose of insulin.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a staff member. During a breakfast pass, a CNA engaged in a heated verbal and physical altercation with a resident in the hallway. The CNA was observed yelling, threatening, and ultimately throwing both a glass of milk and a nearly full gallon of milk at the resident. The incident was witnessed by a CMA and an LPN, who attempted to intervene and de-escalate the situation but were unsuccessful. The CNA continued to act aggressively, including pushing the CMA away and swinging at the resident after slipping and falling. The resident involved had a medical history that included unspecified dementia and schizoaffective disorder, bipolar type. Following the altercation, the resident was found to have a scratch on their forehead, and their glasses were found on the floor with the nose piece stuck in their hair. The incident was captured on facility video surveillance, which confirmed the sequence of aggressive actions by the CNA and the unsuccessful attempts by other staff to protect the resident. The facility's abuse and neglect policy strictly prohibits any kind of abuse against residents. However, after the incident, it was noted that the DON did not provide education on abuse to staff, and the administrator did not come to the facility on the day of the incident. The event was reported to the Oklahoma State Department of Health, and the resident was sent to the hospital for evaluation. The deficiency was identified as the facility's failure to ensure residents were free from abuse.
Failure to Provide Ordered Antipsychotic Medications for Resident with Serious Mental Illness
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, bipolar type, was not provided with their ordered antipsychotic medications, specifically risperidone and Seroquel, for multiple consecutive days following admission. The resident did not receive 12 consecutive doses of risperidone and five consecutive doses of Seroquel due to the medications not being available in the facility. Documentation in the medication administration record repeatedly noted that the medications were "waiting on pharmacy" or "on order," and there was no evidence that the physician was notified about the unavailability of these vital medications. Staff interviews revealed that certified medication aides (CMAs) and nurses were either unaware of the medication orders or did not document notifications to the charge nurse or pharmacy regarding the missing medications. The DON and administrator were not made aware that the medications were unavailable, and the physician confirmed they had not been notified nor had they ordered the medications to be placed on hold. The facility's existing policy required physician notification if three consecutive doses of a vital medication were withheld, refused, or not available, but this protocol was not followed in this case. During the period when the resident was not receiving their prescribed antipsychotic medications, they exhibited escalating behavioral symptoms, including delusions, hallucinations, agitation, and threats toward staff, which ultimately led to emergency room visits and in-patient psychiatric treatment. The failure to ensure the availability and administration of ordered medications for a resident with a serious mental illness constituted a deficiency in providing necessary behavioral health care and services as required.
Failure to Obtain Physician-Ordered Lithium Level Lab Test
Penalty
Summary
The facility failed to ensure that laboratory tests ordered by a physician were obtained for a resident with schizoaffective disorder, bipolar type, who was prescribed lithium. A physician order for admission labs, including a lithium level, was documented, but review of the resident's records and lab order summary showed that the lithium level was neither requested from the lab company nor completed during the resident's stay. An LPN reported not seeing an option to order a lithium level in the lab portal, and the DON was unaware of why the test had not been entered, noting that a staff member mistakenly believed the lithium level would be included in a CBC. The DON also stated that random audits were conducted to ensure labs were obtained as ordered, but the last audit had been conducted over two months prior.
Failure to Monitor and Report Pressure Ulcer
Penalty
Summary
The facility failed to adequately assess, monitor, and intervene for a resident at risk for pressure ulcers, leading to an Immediate Jeopardy situation. A resident, who was totally dependent on staff and at increased risk for pressure ulcer development, was admitted with no initial skin concerns documented. Despite a physician's order for weekly skin assessments, no issues were noted until a family member discovered a wound on the resident's coccyx, which was emitting a foul odor. The wound was significant, measuring 11cm x 13cm with a necrotic bed, and was not reported to the physician until several days later. The delay in notifying the physician and implementing appropriate treatment contributed to the severity of the wound. The Director of Nursing (DON) was informed of the wound by an LPN, who mistakenly believed they had notified the physician and the family, but had not. The physician was eventually notified, and treatment was ordered, but the resident was transferred to the hospital at the family's request. This incident highlights the facility's failure to follow protocols for skin integrity monitoring and timely communication with medical professionals and family members.
Deficiencies in Chemical Security, Smoking Safety, and Bed Rail Assessment
Penalty
Summary
The facility failed to ensure that chemicals were secured in one of the three halls observed for storage of chemicals. During observations, it was noted that the door to a shower room was left open, despite a sign instructing it to be kept closed. Inside, unsecured chemicals such as Xpress detergent disinfectant, Derma daily moisturizing lotion, and Senegence hand sanitizer were found. Additionally, the nursing supply closet was observed to be unsecured, containing items like wound cleanser and shaving cream, which were also labeled to be kept out of reach of children. Staff acknowledged that these areas were supposed to be locked, but they were not. The facility also failed to properly assess a resident for safe smoking practices. A resident with diabetes and end-stage renal disease was observed smoking unsupervised, with a cigarette hanging from their mouth while their eyes were closed. Although the resident was previously assessed as a safe smoker, the incident was not reported or documented by the staff member who witnessed it. The social services director and DON were unaware of the incident until informed by the surveyor, indicating a lapse in communication and monitoring. Furthermore, the facility did not conduct proper assessments or obtain necessary consents for the use of bed rails for a resident with type two diabetes. The resident was observed using bed rails without an order, consent, or assessment documented in their clinical record. The DON admitted that assessments and consents for bed rails were not routinely performed, highlighting a gap in the facility's protocol for ensuring resident safety regarding bed rail use.
Infection Control Deficiencies in Medication and Care Procedures
Penalty
Summary
The facility failed to maintain infection control during blood glucose monitoring and insulin administration for two residents with diabetes mellitus. An LPN was observed not wearing gloves while obtaining blood glucose and administering insulin. The glucometer was not disinfected between uses, contrary to the manufacturer's instructions and facility policy. The LPN admitted to forgetting to don gloves and incorrectly using alcohol pads instead of the required sanitizing wipes for disinfection. Infection control lapses were also noted during medication administration. A CMA was observed handling medication with bare hands, failing to don gloves or sanitize hands, which is against the facility's policy. Another CMA transferred medication between cups with bare hands, acknowledging the mistake. The DON confirmed that gloves should be used when handling pills to prevent contamination. The facility did not ensure proper infection control during wound care and catheter care. An LPN failed to wash hands between glove changes during wound care for two residents. Additionally, catheter care for a resident was performed without sanitizing hands between glove changes, and the catheter bag was observed touching the floor. The DON stated that handwashing is required between glove changes and that surfaces should be sanitized before placing supplies, even when using wax paper.
Failure to Update Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a care plan was reviewed and updated for a resident with a significant medical condition. The resident was admitted with a diagnosis of a stage four pressure ulcer in the sacral region. Upon review of the resident's clinical record, it was found that there was no documentation of the wound or any wound care in the care plan. The MDS coordinator acknowledged that the wound care had not been documented in the care plan, despite believing it had been added. This oversight occurred for one resident out of the 73 residing in the facility.
Unauthorized Wound Treatment Without Physician Orders
Penalty
Summary
The facility failed to ensure that treatments for non-pressure wounds on a resident's toes were ordered by a physician. The resident had non-pressure wounds on the right third toe and left second toe, as documented in their care plan. However, the wound care provided, specifically the application of Betadine, was not authorized by a physician. LPN #1 applied Betadine to the wounds without obtaining the necessary orders, assuming that the wound physician would have ordered it. This action was taken without notifying the wound physician or documenting the new wounds in the progress notes or wound log. LPN #1 admitted to not following the protocol of notifying the DON and obtaining physician orders for the newly identified wounds. The DON confirmed that the nurses were required to notify the physician and obtain treatment orders for any identified wounds. Despite the resident's care plan and the facility's policy requiring physician authorization for wound treatments, LPN #1 did not adhere to these procedures, leading to the deficiency. The physician later confirmed that they did not recall giving an order for Betadine for the resident's wounds.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to ensure that daily weights were obtained for a resident as per the physician's order. The resident in question had end-stage renal disease and cardiac issues, necessitating close monitoring of their weight. The physician's order, dated August 1, 2024, required daily weights to be taken during the day shift starting August 2, 2024. However, a review of the electronic clinical record and paper weight logs from August 2, 2024, to September 5, 2024, showed that weights were only recorded 19 times out of 35 opportunities. The deficiency was attributed to a lack of clarity and communication regarding the responsibility for obtaining daily weights. The Director of Nursing (DON) indicated that the restorative aide was responsible for obtaining and documenting the weights, which were then provided to the MDS coordinator for entry into the electronic record. If the restorative aide was unavailable, the charge nurse was supposed to obtain or assign a CNA to take the weights. However, the MDS coordinator stated they only monitored weekly and monthly weights, not daily ones, leading to confusion about who was responsible for ensuring daily weights were recorded as ordered.
Failure to Administer Enteral Formula as Ordered
Penalty
Summary
The facility failed to administer enteral formula as ordered by the physician for a resident who required tube feeding. The resident had a diagnosis that included attention to a gastrostomy and was ordered Nutren 1.5 continuous at 60 ml/hr according to the physician's order dated 07/02/24. However, observations on multiple occasions revealed that the resident was receiving Nutren 1.5 at 50 ml/hr instead of the prescribed 60 ml/hr. An LPN, upon reviewing the electronic clinical record and the label on the formula bag, confirmed the discrepancy and acknowledged the error. The Director of Nursing (DON) also reviewed the records and confirmed the resident was ordered 60 ml/hr, but could not explain why the resident was receiving 50 ml/hr. The DON stated that nurses on each shift were responsible for verifying the correct formula and rate were being administered.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre and post dialysis assessments for a resident with end-stage renal disease who required dialysis three times a week. The resident had a physician's order and a care plan indicating the need for dialysis on specific days, and staff were instructed to monitor for signs of infection, renal insufficiency, and the shunt access site. However, a review of the electronic clinical record revealed that these assessments were not documented. Interviews with staff, including an LPN and the DON, revealed that pre and post dialysis assessments were not performed or documented. The LPN mentioned monitoring for bleeding and nausea but did not document these observations. The DON acknowledged that they were supposed to check on the resident after dialysis, obtain vital signs, and implement any new orders from the dialysis center, but they were unaware that pre and post dialysis assessments were required. The administrator also noted that admitting residents who required dialysis was new to the facility, indicating a lack of awareness and preparation for the necessary care procedures.
Failure to Assess and Inspect Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to assess and inspect bed rails to identify any risks of entrapment for a resident who utilized bedrails. During an observation, the resident was seen lying in bed with the bed rails in the up position. An LPN stated that the resident used the bed rails to reposition themselves and that bed rails were supposed to be reassessed monthly, with documentation in the electronic clinical record. However, the last assessment for the resident was completed several months prior. A maintenance worker mentioned that they installed or removed bedrails based on orders and addressed any issues reported by CNAs or nurses, but did not routinely check them. The DON noted that bed rails were not usually utilized unless requested by a resident.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the required state agencies within the mandated time frame for two residents. Resident #1, diagnosed with Parkinson's disease and physical debility, was dependent on staff for hygiene and toileting. An allegation of sexual abuse against a CNA was documented on 06/15/24, but the CNA was not reported to the authorities until 06/18/24, three days after the incident. This delay in reporting violated the facility's policy, which requires immediate reporting within two hours of an abuse allegation. Similarly, Resident #2, who had major depressive disorder, dysphagia, intellectual disability, and cognitive impairment, was involved in an incident where possible exploitation was reported. The facility was notified on 06/13/24 about a video involving the resident and two staff members. However, the staff members were not reported to the authorities until 06/14/24, two days after the initial notification from the sheriff's office. The facility's administrator was unaware of the two-hour reporting requirement, which contributed to the delay in reporting these incidents.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care. The resident, who had diagnoses including Parkinson's disease and physical debility, required assistance with activities of daily living (ADLs) and was incontinent of bladder. On a specific date, an LPN and a CNA entered the resident's room to provide incontinent care. Although the door was closed, the privacy curtain was not used, leaving the resident exposed from the waist down when the CNA exited the room to obtain additional supplies. The LPN confirmed that the resident was exposed during this time.
Inadequate Pressure Ulcer Assessment and Monitoring
Penalty
Summary
The facility failed to implement its pressure ulcer policy effectively, resulting in inadequate assessment and monitoring of a new pressure wound for one of the residents. The facility's policy, revised in April 2018, requires a full assessment of pressure ulcers, including location, stage, and measurements. However, the documentation for the resident in question was inconsistent and incomplete, failing to provide necessary details about the pressure ulcer's location, size, and condition. The resident, who had diagnoses including Parkinson's Disease and physical debility, was documented to have various skin issues, including bruises, skin tears, and an unstageable ulcer. Despite these findings, the clinical records lacked comprehensive documentation of the pressure ulcer, with several assessments failing to mention the ulcer's location or provide a description. The inconsistency in documentation persisted over several days, with some assessments noting the presence of pressure ulcers without further details, while others did not mention them at all. The Director of Nursing (DON) acknowledged the discrepancies in the documentation and the lack of proper monitoring of the pressure wound. The DON admitted that the wound should have been measured and documented with each treatment, as per the facility's policy. The failure to maintain accurate and complete records of the resident's pressure ulcer care highlights a significant deficiency in the facility's adherence to its own clinical protocols.
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 122 citations issued within 25 miles in the last 12 months — including the 5 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 Tulsa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Manor Nursing Home | 2.1 mi | ★★★★★ | 2 | 0 |
| Ambassador Manor Nursing Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Covenant Living At Inverness | 2.4 mi | ★★★★★ | 1 | 0 |
| Zarrow Pointe | 2.5 mi | ★★★★★ | 0 | 0 |
| The Villages At Southern Hills | 2.7 mi | ★★★★★ | 0 | 0 |
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