Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 The Grand At Bethany Skilled Nursing And Therapy during CMS and state inspections, most recent first.
A resident with a new schizophrenia diagnosis and ongoing antipsychotic use was not referred for a level II PASARR evaluation. Record review showed an earlier level I PASARR did not identify SMI, but the resident later had schizophrenia documented and received olanzapine. Staff stated that a new SMI diagnosis should trigger referral to OHCA for level II screening.
Care plan omitted hearing aid needs. A resident with moderate cognitive impairment and documented HOH was observed without hearing aids, and the resident stated they did not know where the aids were. The care plan did not include a focus, goal, or interventions for hearing aids, even though progress notes and assessments documented use of hearing aids for communication and staff interviews confirmed the aids should have been included in the care plan, orders, and tasks.
Care plan lacked specific vision-related interventions for a resident with severely impaired vision. The resident stated staff had not shown them how to get around the facility or assisted them to and from the dining room, and they relied on other residents for help. The MDS coordinator stated the care plan did not include specifics for how to assist the resident and that there was no process in place for assisting blind residents.
A resident receiving dialysis did not have a documented post-dialysis assessment after returning from treatment. The dialysis communication forms were often incomplete, with blank section B entries and inconsistent pre-dialysis documentation, and the chart lacked return time, vital signs, access site findings, dressing status, peripheral pulse checks, behavior, or complaints. Staff said they mainly transcribed the dialysis center’s notes instead of documenting their own assessment.
A resident with multiple complex medical conditions developed a stage III pressure ulcer after admission, despite initial preventive orders. Documentation and interviews revealed the resident was not consistently turned or repositioned, and family members had to request staff assistance. The DON acknowledged care challenges and inconsistencies in wound documentation, resulting in a deficiency in pressure ulcer prevention and management.
Two residents were found to have inaccurate assessments, including discrepancies in documentation of pressure ulcers and dental status. One resident's records conflicted regarding the presence of pressure injuries upon admission, while another was incorrectly documented as having natural teeth and no chewing difficulty, despite being edentulous and reporting problems with chewing. Facility staff acknowledged the inaccuracies in the assessments.
A resident with significant vision impairment and a history of glaucoma and macular degeneration did not have a required follow-up eye appointment scheduled, as documented in their clinical record. The resident, who was cognitively intact, reported missing the appointment, and staff later confirmed the oversight, citing possible communication issues.
An Immediate Jeopardy situation occurred when staff at a facility failed to verify a resident's DNR status before initiating CPR. The resident, who had a DNR order, became unresponsive in a whirlpool tub. Despite a color-coded system to indicate DNR status, staff were unaware or misunderstood its meaning, leading to CPR being performed contrary to the resident's wishes. The deficiency was noted as an isolated incident with potential for more than minimal harm.
A resident with multiple health conditions was left unsupervised in a whirlpool tub, leading to their unresponsiveness and subsequent death. The facility's policy required staff to remain with residents during whirlpool baths, but this was not followed. The resident had been taking unsupervised whirlpool baths for a long time, and the emergency call system was not activated during the incident.
Two residents in a facility reported abuse and misappropriation by a staff member. One resident, with cerebral infarction and quadriplegia, alleged sexual assault and theft of personal drinks by a CNA. Another resident, with dementia and hemiplegia, reported rough treatment and theft by the same CNA. The facility's administrator confirmed the allegations, leading to the CNA's termination.
A resident with a history of intracerebral hemorrhage and other conditions required two staff for transfers. However, during a transfer, the resident was lowered to the floor, resulting in a fractured femur. The CNA involved did not consult the care plan, and there was uncertainty about staff availability to assist. The resident was hospitalized and returned with staples and a fracture diagnosis.
Two residents reported being handled roughly by a CNA, with one resident feeling the treatment was abusive and reporting it to a social worker, leading to police involvement. The facility's policy on abuse was not effectively implemented, resulting in a deficiency.
The facility failed to ensure complete Advance Directive and DNR documentation for two residents, with forms either unsigned or missing from records. Additionally, a resident's DNR order was improperly executed, lacking necessary signatures and documentation, leading to an invalid DNR status.
A resident with type two diabetes did not receive their scheduled Tresiba insulin doses on multiple occasions, and the facility failed to notify the physician as required. The LPN marked the insulin as not required due to low blood sugar levels, but there were no parameters in the order to hold the medication, and no documentation was made in the resident's progress notes. The DON confirmed the lack of notification and documentation, which was against the facility's policy.
The facility failed to implement fall interventions for three high-risk residents. Despite care plans specifying that beds should be in the lowest position, observations showed beds in high or medium positions. Additionally, a fall mat was not properly placed for one resident. The Administrator and CNA confirmed the care plans were not followed.
The facility failed to update care plans for four residents, resulting in outdated and inaccurate documentation. A resident's care plan was not revised with the latest assessment, while three others, identified as high fall risks, had care plans that were not followed, as their beds were not kept in the low position as required. Staff were aware of the residents' preferences for higher bed positions, but care plans were not updated accordingly.
The facility failed to provide scheduled bathing assistance to three residents, resulting in missed baths over several months. A resident with severe cognitive impairment and two others requiring assistance did not receive baths as per their schedules. Family members and residents reported dissatisfaction, and the DON confirmed the missed baths upon reviewing records.
The facility failed to administer medications as ordered for two residents, leading to deficiencies in pharmaceutical services. A resident with diabetes had insulin held without a physician's order, and another resident received an antibiotic earlier than scheduled without proper authorization. The facility's policies on medication timing and documentation were not followed, resulting in discrepancies in medication administration.
The facility failed to properly label and store medications in a medication room and two nurse medication carts. A medication room refrigerator lacked a lock, and controlled medications were not stored as required. Insulin pens for multiple residents were found without open or discard dates. Additionally, medications for discharged residents were not removed from the carts. The DON acknowledged that facility policies were not followed.
The facility did not ensure snacks were proactively offered to all residents. Observations showed that snacks were available at nurses' stations and on hydration carts, but staff did not consistently offer them to residents. Only those who requested snacks received them, indicating a lack of proactive distribution by staff.
A resident with vascular dementia and hypertension was found with three bottles of eye drops in their room, one missing a cap. The resident used the drops multiple times daily without a physician's order or a self-administration assessment. An LPN confirmed the lack of documentation, and the DON stated that such an order and assessment are required.
The facility did not ensure that the most recent survey results were accessible to residents, family members, and legal representatives. A book labeled 'survey results' was found with outdated information, with the latest results from a Covid-19 focused survey dated 12/07/20. The Administrator confirmed the outdated status and acknowledged responsibility for updating the survey book. The Resident Council Group also stated that State inspection results were not available for residents to read.
A resident with a left femur fracture did not receive proper wound care after the discontinuation of a wound vac. The resident reported no staff checked the wound since the vac was removed, and greenish drainage was observed on the dressing. An LPN confirmed the lack of wound care orders for the current dressing, and the Wound Care Nurse admitted to not updating the orders while waiting for new instructions from the surgeon.
The facility did not post complete nurse staffing information, omitting the facility name, census, and actual hours worked for each staff member. The Regional Nurse Consultant confirmed the absence of a policy for nursing staff postings, and the Payroll Clerk admitted to retaining staffing information for only one pay period, failing to maintain 18 months of records.
The facility failed to maintain cleanliness and repair in the kitchen and did not remove expired foods from circulation. Observations revealed missing baseboards, residue, chipped paint, and rusted pipes in the dish machine area. Expired baking powder, raspberry dessert topping, and barbeque sauce were found in use. Staff acknowledged these issues, and the Administrator was unaware of the repair needs.
A resident with osteoporosis and muscle atrophy did not receive prescribed PT services due to a lack of communication and coordination between the facility, PT provider, and insurance. Despite a physician's order and good rehab potential, the PT plan was not executed as the PT provider did not receive payment, and the facility failed to follow up on insurance authorization.
A facility failed to ensure a resident's Advance Directives were accessible to direct care staff. The resident, with intact cognition and conditions including aphasia and hemiparesis, had an undated and unsigned DNR Consent form indicating an Advance Directive was provided to the facility. However, it was not found in the resident's hard or electronic chart. The facility was transitioning to electronic records, and the document was located in a program only accessible to administrative staff, not direct care staff.
A facility failed to maintain infection control during incontinent care for two residents. A CNA did not change gloves between dirty and clean tasks while assisting a resident with cerebral infarction and another with dementia. The CNA was unsure about the frequency of glove changes, and the DON later clarified that gloves should be changed as needed during care.
The facility did not report an abuse allegation within the required two-hour timeframe to OSDH. A resident reported being raped to a driver, but the incident was not officially reported until two days later. The Administrator, aware of the allegation, could not provide documentation of timely reporting as per facility policy.
Failure to Refer Resident With New SMI for Level II PASARR
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed serious mental illness for a level II PASARR evaluation. Record review showed the resident had a level I PASARR dated 03/22/16 with a primary diagnosis of cerebrovascular accident and no indication of serious mental illness, but an admission record dated 03/11/25 documented a diagnosis of schizophrenia on 11/22/22. The resident’s record also showed routine use of antipsychotic medication, including a quarterly assessment dated 12/10/25 and a physician’s order dated 12/16/25 for olanzapine 2.5 mg at bedtime. The health record did not show that the resident was screened for a level II PASARR when schizophrenia was diagnosed. Corporate nurse #1 stated that after the resident was diagnosed with a serious mental illness, the facility should have referred the resident for a level II evaluation, and the MDS coordinator stated that residents with a new diagnosis of a serious mental illness should be referred to the OHCA for a level II screening.
Care plan omitted hearing aid needs
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed to include a hearing aid for Resident #1, one of 24 sampled residents reviewed for comprehensive care plans. Resident #1 had a BIMS score of 12 and was documented as having moderate cognitive impairment. A Comprehensive Activity Assessment dated 9/26/25 showed hearing in both ears was adequate when using hearing aids, and an admission assessment dated 10/19/25 showed the resident was wearing hearing aids and had minimal difficulty hearing during the assessment. Physician progress notes dated 11/06/25 and 11/11/25 identified the resident as hard of hearing and using hearing aids for communication. On 12/30/25 at 12:02 p.m., Resident #1 was observed not wearing hearing aids and stated they did not know where the hearing aids were but wanted staff to help find them. The resident’s care plan dated 11/05/25 did not include a focus, goal, or interventions addressing hearing aids as an intervention for the resident’s communication problem and hearing deficit. During interviews, CMA #1 stated they were not aware the resident had hearing aids, CMA #2 stated the resident had hearing aids and misplaced them sometimes and that they should be in the care plan, the ADON stated hearing aids should be part of the care plan, and the MDS coordinator stated the hearing aids were not in the care plan and should be included in the care plan, orders, and tasks.
Care Plan Lacked Vision-Related Interventions for Blind Resident
Penalty
Summary
The facility failed to develop a care plan within 7 days of the comprehensive assessment that included interventions for orientation, education, and guidance about the facility for a resident with severely impaired vision. Resident #17’s admission assessment dated 11/04/25 showed the resident had severely impaired vision with no vision or only light, colors, or shapes, and that the eyes did not appear to follow objects. However, the undated care plan did not show how staff assisted the resident with mobility or guidance about the facility. During interview, Resident #17 stated on 12/30/25 that they had not been shown how to get around the facility and that staff did not assist them to and from the dining room. The resident stated they asked other residents for help and felt staff were not aware of the assistance they needed. On 01/02/26, the MDS coordinator stated the resident would gain familiarity and independence through constant intervention and that staff should let the resident know their environment and help them, including assisting with meals if the resident could not read the menu. The MDS coordinator also stated they did not see any specifics in the care plan about how to assist the resident and that the care plan only showed to assist them; they further stated there was no process in place for assisting blind residents.
Incomplete Dialysis Return Assessments
Penalty
Summary
The facility failed to perform and document a post-dialysis assessment for a resident who required dialysis services. Record review showed multiple dialysis communication forms in which the pre-dialysis section was completed inconsistently, but the post-dialysis section was often blank. The forms also did not include a place for the facility to document its own post-dialysis assessment. For several dialysis dates, the resident’s pre-dialysis weight remained documented from earlier dates, and some forms lacked documentation of pre-dialysis assessment items such as thrill, bruit, dialysis site examination, or peripheral pulses. The clinical record contained no documentation of when the resident left for dialysis or returned to the facility on the reviewed dates. There was also no documentation of the resident’s condition upon return, including vital signs, the appearance or sound of the dialysis access, the condition of the dressing, the status of peripheral pulses, the resident’s behavior, or whether the resident had any complaints. The resident stated that staff performed a pre-dialysis assessment but not a post-dialysis assessment. Staff interviews confirmed that nurses were transcribing what dialysis center staff wrote in section B of the communication form rather than documenting their own post-dialysis assessment. One LPN stated they checked the dialysis site for bleeding but did not perform or document a full assessment, and did not check the thrill, bruit, or vital signs when the resident returned. Another LPN stated they checked vital signs for stability but did not document them or perform an assessment. The ADON and a corporate nurse consultant stated the facility nurses documented the dialysis center’s information and did not document their own assessment, and the corporate nurse consultant stated the facility did not document return time, thrill/bruit checks, site observations, dressing removal time, or the resident’s condition after dialysis.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
A resident with a history of cardiac arrest resulting in anoxic brain damage, congestive heart failure, hypernatremia, acute respiratory failure with hypoxia, acute kidney injury, and PEG tube status was admitted to the facility. Upon admission, a skin assessment noted redness and superficial breakdown on the sacrum, with orders for cleansing and application of Triad cream for wound prevention. Five days later, a subsequent skin assessment documented shearing to the sacrum and indicated that a pillow was being used to offload pressure, with continued monitoring and prevention as ordered. However, a wound care note shortly thereafter identified a stage III pressure injury on the sacrum, measuring 6cm x 11cm x 0.2cm, with serosanguineous drainage, and treatment orders were updated to include Triad cream and a bordered foam dressing. Interview with the resident's family member revealed concerns that the resident was not being turned and repositioned as needed and was not receiving adequate hydration. The family member reported having to seek out nursing staff to turn the resident during visits. The DON acknowledged the resident required total care and had significant edema, and also noted discrepancies in wound documentation between nursing staff and wound care personnel. The findings indicate a failure to provide consistent and adequate care and services to prevent the development or worsening of pressure ulcers for this resident.
Inaccurate Resident Assessments Documented
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents. For one resident, the admission assessment indicated moderate cognitive impairment and no unhealed pressure ulcers or deep tissue injuries upon admission. However, the discharge assessment later documented the presence of one unstageable pressure ulcer and two unstageable deep tissue injuries as being present upon admission or reentry, which was inconsistent with the initial assessment. For another resident, the admission assessment documented that the resident was not edentulous, despite observations and interviews confirming the resident had no natural teeth and did not have dentures. The quarterly assessment also failed to note the resident's difficulty chewing, which was reported by both the resident and a family representative. Both the DON and the MDS coordinator acknowledged that the assessments were inaccurate regarding the resident's dental status and the presence of pressure injuries.
Failure to Schedule Follow-Up Eye Appointment for Resident with Impaired Vision
Penalty
Summary
The facility failed to ensure that a follow-up eye appointment was scheduled for a resident with highly impaired vision and diagnoses of glaucoma and macular degeneration. Documentation from a local eye specialty hospital indicated a follow-up was needed in approximately four months, but there was no record in the clinical file that the appointment had been scheduled. The resident, who was cognitively intact, reported missing the appointment and believed it had been forgotten. Facility staff confirmed the missed appointment after being contacted by the resident's family member, but could not provide a reason for the oversight, suggesting a possible lapse in staff communication.
Failure to Verify DNR Status Before Initiating CPR
Penalty
Summary
An Immediate Jeopardy situation was identified at a facility due to the failure of staff to verify a resident's code status before initiating CPR. A resident, who had a Do Not Resuscitate (DNR) order, became unresponsive while in a whirlpool tub. Staff began CPR without confirming the resident's DNR status, which was later verified through the resident's care plan and physician's order. The facility had a policy in place to comply with residents' advanced directives, including DNR orders, but staff were not adequately informed or trained to identify these directives in an emergency. The facility used a color-coded system with red and green name plates on residents' doors to indicate DNR status, but staff were either unaware of this system or misunderstood its meaning. Interviews with staff revealed confusion about the color codes and a lack of knowledge regarding the resident's DNR status at the time of the incident. The resident involved had a history of chronic obstructive pulmonary disease, hypertension, and other medical conditions. Despite having a DNR order documented in their care plan and medical records, the staff's failure to verify this information before starting CPR led to the Immediate Jeopardy finding. The deficiency was noted as an isolated incident with the potential for more than minimal harm.
Failure to Supervise Resident in Whirlpool Tub
Penalty
Summary
An Immediate Jeopardy situation was identified in a facility due to the failure to supervise a resident while in a whirlpool tub, resulting in the resident becoming unresponsive and subsequently being pronounced deceased. The resident had a history of chronic obstructive pulmonary disease, hypertension, recurrent depressive disorder, diabetes with a history of ketoacidosis with coma, transient ischemic attack, and cerebral infarction without residual deficits. The resident's care plan indicated they were at risk for ADL self-care performance deficit and required setup or clean-up assistance with bathing/showering, although they were independent with transferring in and out of the tub or shower. On the day of the incident, the resident was placed in the whirlpool tub by a CNA, who then left the room, setting a timer for the resident's requested additional time in the tub. The CNA reported that the resident did not like staff to stay in the whirlpool room with them, and the CNA was observed walking in the halls while the resident was in the whirlpool. When the CNA returned, they found the resident unresponsive, with their head slumped forward but not underwater. Despite attempts to revive the resident, they were pronounced deceased by emergency medical services. Interviews with staff revealed that the facility's policy required staff to remain with residents for safety during whirlpool baths, but this policy was not followed. The CNA involved stated they were unaware of the requirement to stay with the resident and had been told the resident only needed setup assistance. Other staff members confirmed that the resident had been taking whirlpool baths without supervision for a long time, and the emergency call system in the whirlpool room was not activated during the incident.
Failure to Protect Residents from Abuse and Misappropriation
Penalty
Summary
The facility failed to protect two residents from abuse and misappropriation of property by a staff member. Resident #1, who had diagnoses including cerebral infarction, quadriplegia, and anxiety, reported being sexually assaulted by a female staff member, identified as CNA #1, who also allegedly stole their personal drinks. The resident, who had intact cognition, described the incident where the staff member touched their groin and made inappropriate comments. Additionally, the resident reported that the aide frequently took their drinks without permission. Resident #2, diagnosed with dementia, COPD, and hemiplegia, also reported mistreatment by the same staff member. The resident, with moderately impaired cognition, alleged that CNA #1 was rough during care and stole their personal drinks. The facility's administrator confirmed the allegations against CNA #1, who was subsequently terminated. The incidents were documented in incident reports submitted to the OSDH, and the facility's policy on abuse and misappropriation was not adhered to, resulting in these deficiencies.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to ensure proper transfer techniques were followed, resulting in an accident for a resident. The resident, who had a history of intracerebral hemorrhage, speech deficit, and convulsions, required the assistance of two staff members for transfers as documented in their care plan. However, during a transfer, the resident was lowered to the floor, leading to a fractured femur. The incident was documented in a progress note, and the resident was subsequently hospitalized, returning with 15 staples and a diagnosis of a fracture of the neck of the right femur. Interviews conducted revealed that the CNA involved in the transfer did not consult the care plan to verify the required transfer procedure. The LPN on duty questioned whether the fracture occurred during the lowering process and noted uncertainty about the availability of sufficient staff to assist with the transfer. The administrator confirmed that the CNA had been trained on transfer procedures but failed to follow the care plan. Attempts to interview the resident and their emergency contacts were largely unsuccessful, and the CNA could not be reached for further comment.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving two residents who reported being handled roughly by a CNA. One resident, who was severely cognitively impaired and dependent on assistance for most activities of daily living (ADLs), was unable to effectively communicate their needs during an interview. The other resident, who was cognitively intact but also dependent on assistance for most ADLs, reported that the CNA had been wiping them roughly and did not adjust when they complained of pain. This resident felt the treatment was abusive and reported it to the social worker, which led to police involvement. The facility's policy on abuse, neglect, and misappropriation of property states that residents have the right to be free from various forms of abuse and that alleged perpetrators should be removed from access to residents. Despite this policy, the incident occurred, and the facility's records documented that the police were notified, and the involved staff and residents were interviewed. The facility's failure to prevent the abuse and ensure the safety and protection of the residents led to the deficiency.
Incomplete Advance Directive and DNR Documentation
Penalty
Summary
The facility failed to ensure that the Advance Directive DNR Consent Admission Acknowledgement forms were complete for two residents. One resident, diagnosed with aphasia and hemiplegia, had an undated and unsigned form indicating they had an Advance Directive and DNR Consent, but no documentation was found in their chart. The Admissions Coordinator and Administrator confirmed the absence of the document in both the paper and electronic records, and the Administrator noted that the DNR had been revoked without a clear reason for the incomplete form. Another resident, diagnosed with Alzheimer's and osteoporosis, had a form indicating they did not have an Advance Directive or DNR Consent, but the form was also undated and unsigned. The Director of Nursing (DON) was unable to confirm if the Advance Directive had been offered to this resident upon admission, and the electronic health record (EHR) was found to be blank regarding this documentation. Additionally, the facility failed to properly execute a DNR order for a resident with atherosclerotic heart disease. Although the resident's code status was documented as DNR in both the physician's order and the EHR, the Oklahoma DNR Consent form was signed by the resident's spouse but lacked a date and witness signatures. Furthermore, there was no power of attorney, health care proxy, or guardianship paperwork for the spouse in the resident's medical record. The DON confirmed that the incomplete DNR Consent form was not valid, and the resident should be considered a full code.
Failure to Notify Physician of Held Insulin Dose
Penalty
Summary
The facility failed to notify the physician when they held a routine insulin dose for a resident diagnosed with type two diabetes mellitus without complications. The resident had a physician order for Tresiba Flextouch subcutaneous solution pen injector, to be administered daily. However, the insulin was not administered on several occasions in July and August 2024, as documented by a code indicating that sliding scale insulin was not required. Despite this, there were no parameters in the physician's order allowing for the insulin to be held, and there was no documentation that the physician was notified of the decision to withhold the medication. Interviews with the LPN and the DON revealed that the staff did not follow the facility's policy, which required notifying the physician of any significant changes in treatment. The LPN admitted to marking the insulin as not required due to low blood sugar levels but did not notify the physician or document the decision in the resident's progress notes. The DON confirmed that the physician should have been notified and that there were no hold parameters in the Tresiba order. This oversight resulted in a failure to adhere to the facility's policy for notifying physicians of changes in a resident's treatment plan.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall interventions for three residents who were identified as being at high risk for falls. Resident #10, diagnosed with Alzheimer's disease, osteoporosis, and rheumatoid arthritis, had a care plan that included keeping the bed in the lowest position. However, observations on multiple occasions showed the bed in a high position, contrary to the care plan. Similarly, Resident #62, with morbid obesity and major depressive disorder, was also observed with the bed in a high position despite the care plan specifying it should be in the lowest position. Resident #82, diagnosed with acute kidney failure, had a care plan that included keeping the bed in the lowest position and ensuring a fall mat was at the bedside. Observations revealed the bed was at medium height, and the fall mat was not in place but folded beside the cupboard. The Administrator and CNA confirmed that the care plans for these residents were not implemented as required, indicating a failure in adhering to the prescribed fall prevention measures.
Failure to Update and Follow Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to revise care plans for four residents, leading to discrepancies between documented care and actual care provided. Resident #103's care plan was not updated with the quarterly assessment, showing outdated information about receiving skilled services and having a urinary tract infection, neither of which were current. The MDS Coordinator acknowledged the oversight, noting that care plans should be updated with significant changes in resident function. Additionally, residents #10, #62, and #82, all identified as high fall risks, had care plans that were not followed. Observations showed these residents' beds were not in the low position as documented in their care plans. CNA #4 reported that these residents preferred their beds in higher positions and had communicated this to the nurses and administrator. The administrator confirmed awareness of the residents' preferences and acknowledged that care plan updates should have been made to reflect these changes.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide scheduled bathing assistance to three residents, leading to a deficiency in care. Resident #1, who had severe cognitive impairment and was dependent on staff for bathing due to hemiplegia and hemiparesis, missed several scheduled baths over three months. Family members reported ongoing issues with bathing assistance, and the Director of Nursing (DON) confirmed the missed baths upon reviewing the records. Resident #103, with intact cognition but requiring substantial assistance for bathing, also missed multiple scheduled baths. The resident expressed dissatisfaction with the irregularity of their bathing schedule, describing it as a primary complaint. Despite the resident's ability to partially bathe themselves, the facility failed to adhere to the scheduled bathing days, as confirmed by the DON and Regional Nurse Consultant. Resident #60, who was cognitively intact but dependent on others for bathing, did not receive baths as scheduled on several occasions. The resident reported receiving baths only once a week, contrary to their schedule. The Assistant Director of Nursing (ADON) confirmed that the lack of documentation indicated the baths were not given, and there was no record of the resident refusing baths.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to deficiencies in pharmaceutical services. Resident #103, diagnosed with type two diabetes mellitus, had specific physician orders for Tresiba and Novolog insulin administration. However, the insulin was not administered according to the prescribed parameters. Tresiba was held without a physician's order on multiple occasions in July and August 2024, despite no hold parameters being specified in the order. Additionally, Novolog was administered outside the ordered parameters, with no documentation of blood sugar rechecks or physician notification when insulin was held. Resident #37, with diagnoses including Stage 3 CKD and an infection of an amputation stump, was prescribed meropenem to be administered intravenously every 12 hours. On one occasion, the medication was administered three hours earlier than scheduled without a physician's order to adjust the administration time. Furthermore, the medication administration was signed off by a different LPN than the one who administered it, which is against facility policy. The DON confirmed that the facility policy requires medications to be given within a one-hour window of the scheduled time unless a physician's order states otherwise, and only the administering nurse should sign the MAR. These incidents highlight a failure in adhering to medication administration protocols, including the lack of proper documentation and communication with physicians when deviations from prescribed orders occur. The facility's policies on medication administration timing and documentation were not followed, leading to discrepancies in the administration of insulin and antibiotics for the residents involved.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications in one medication room and two nurse medication carts. During a review of the medication room on Hall 200, it was found that the refrigerator lacked a lock, and controlled medications were not stored in the locked box as required. Additionally, medication for a resident who had expired was still present in the refrigerator, and a box of arformoterol inhalation solution with conflicting expiration dates was also found. Insulin pens for multiple residents were stored without open or discard dates, contrary to facility policy. Further inspection of the medication carts on Halls 200 and 300 revealed similar issues. Opened insulin pens and vials on the carts lacked open and discard dates. Medications for discharged residents were still on the cart, which should have been removed and given to the DON for disposal. The DON confirmed that the facility's policies regarding medication storage, labeling, and disposal were not followed, leading to these deficiencies.
Failure to Proactively Offer Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were offered to all residents, as observed during a survey. The Resident Council Group reported that while snacks were available, residents had to request them or retrieve them themselves, and staff did not actively pass snacks to residents. Observations confirmed that snacks were placed at nurses' stations and on hydration carts, but staff did not consistently offer them to residents. Only those residents who asked for snacks received them, indicating a lack of proactive distribution by the staff. During the observation period, staff were seen offering water and ice to residents but not snacks, except when specifically requested by residents. Interviews with staff, including CNAs and the Administrator, revealed that there was no set procedure for passing snacks, and it was assumed that residents would either ask for them or get them on their own. This practice led to a deficiency in meeting the residents' needs for snacks, as not all residents were offered snacks during the observed period.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was safe to self-administer medications, as observed in the case of a resident with vascular dementia and hypertension. During an observation, three bottles of eye drops were found in the resident's room, with one bottle missing a cap and being wrapped with a tissue. The resident reported using the eye drops at least four times a day. However, there was no documentation of a physician's order allowing the resident to self-administer medications, nor was there a completed self-administration assessment. An LPN retrieved the eye drops and confirmed upon reviewing the resident's health record that there was no physician's order or assessment for self-administration. The Director of Nursing later stated that self-administration of medications requires a physician's order and a completed assessment, which had not been done in this case.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent surveys were available to residents, family members, and legal representatives. During an observation on Hall 100, a book labeled 'survey results' was found containing outdated information, with the latest survey results dated 12/07/20. These results documented a Covid-19 focused infection control survey, indicating the facility was in substantial compliance at that time. However, the Administrator, upon reviewing the book, confirmed that the latest survey results were indeed from 12/09/20 and acknowledged their responsibility for keeping the survey book up to date. Additionally, the Resident Council Group confirmed that the results of the State inspections were not available for residents to read.
Failure to Provide Appropriate Wound Care
Penalty
Summary
The facility failed to ensure proper wound care for a resident with a displaced subtrochanteric fracture of the left femur. The resident had a physician's order for wound care involving a wound vac, which was discontinued on 08/23/24. However, the resident reported that no staff had checked on the wound since the wound vac was removed, and there was greenish drainage on the dressing. LPN #6 confirmed the presence of greenish drainage and noted that the current dressing did not have corresponding wound care orders. Wound Care Nurse #1 acknowledged discontinuing the wound vac and applying a new dressing on 08/23/24, but they were waiting for new wound care orders from the resident's surgeon. The nurse admitted that they should have updated the resident's orders with the new dressing. This oversight resulted in the resident not receiving appropriate wound care as per the physician's orders, potentially leading to an increased risk of infection.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted with all required components and was accessible to all residents. During a tour of the facility, it was observed that the nursing staffing boards on each hall did not include the facility name, the census, or the actual hours worked for each staff member. The Regional Nurse Consultant confirmed that the census and facility name were missing from the board and acknowledged the absence of a policy for nursing staff postings. Additionally, the Payroll Clerk stated that staffing information was only retained for one pay period at a time, and they did not maintain 18 months of posted staffing information as required.
Kitchen Cleanliness and Expired Food Issues
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in the kitchen, as well as to remove expired foods from circulation. During a tour of the kitchen, it was observed that baseboards were missing in the dish machine area, and there was black and brown residue along the walls and floor. The paint on the floor was chipped and peeled, and there were rusted metal pipes and stained white pipes. Additionally, expired baking powder, raspberry dessert topping, and barbeque sauce were found in use. A staff member acknowledged that these items were expired and should not have been on the shelf, despite weekly checks for expirations. The Assistant CDM confirmed the need for new paint or flooring and acknowledged the missing baseboards, stating that the facility was aware of these repair needs. The dish machine area was supposed to be cleaned after every shift, but the Administrator was unaware of the repair needs.
Failure to Provide Physical Therapy Services
Penalty
Summary
The facility failed to provide necessary physical therapy (PT) services to a resident, who was diagnosed with age-related osteoporosis and required assistance with activities of daily living. A physician's order was issued for the resident to receive PT three times a week for 60 days to address muscle wasting, atrophy, and lack of coordination. Despite the resident's good rehabilitation potential and the goal to improve strength and mobility, the PT services were not initiated. The resident expressed concerns about not receiving PT and mentioned that their insurance company confirmed eligibility for the services. The deficiency arose due to a lack of communication and coordination between the facility, the PT provider, and the insurance company. The PT provider did not receive payment for the evaluation and plan of treatment, which led to the discontinuation of services. The Business Office Manager (BOM) was unaware of the facility's process for following up on PT evaluations and did not receive the necessary documentation for insurance authorization. The facility was unable to provide documentation of an insurance denial for the PT services, and the resident's grievance about not receiving PT was not addressed until much later.
Advance Directives Not Accessible to Direct Care Staff
Penalty
Summary
The facility failed to ensure that the Advance Directives for a resident with diagnoses including aphasia, hemiplegia, and hemiparesis following a cerebral infarction were accessible to direct care staff. The resident's cognition was documented as intact in a recent assessment. An undated and unsigned Advanced Directive DNR Consent form indicated that the resident had an Advance Directive and a DNR Consent, and that a copy had been given to the facility. However, upon review, no Advance Directive was found in either the resident's hard chart or electronic chart. The facility was in the process of transitioning to electronic medical records, and the Administrator confirmed that Advance Directives should be scanned into the electronic record under documents. Despite this, the Administrator was unable to locate the resident's Advance Directive in the electronic record. It was found under a specific MR Program, which was only accessible to certain administrative staff, not direct care staff. This lack of access for direct care staff contributed to the deficiency in ensuring the resident's Advance Directives were readily available.
Infection Control Deficiency During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the provision of incontinent care for two residents. Resident #40, who had diagnoses including cerebral infarction and chronic pain, required physical assistance with toileting hygiene due to moderate cognitive impairment. On the morning of August 28, CNA #8 provided incontinent care to Resident #40 without changing gloves between dirty and clean tasks. The CNA continued to wear the same gloves while performing various tasks such as adjusting the resident's pillow, handling the bed remote, and lowering the bed, before finally removing the gloves and washing their hands. Similarly, Resident #15, who had severe cognitive impairment and required assistance with toileting hygiene, was also subject to improper infection control practices. CNA #8 provided incontinent care to Resident #15, initially wearing the same gloves throughout the process. Although the CNA changed gloves once during the care, they were unsure about the frequency of glove changes required. The Director of Nursing later stated that gloves should be changed as needed during incontinent care, specifically between dirty and clean tasks.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Oklahoma State Department of Health (OSDH) for one of the three sampled residents. The facility's policy, revised in September 2016, mandates that the Director of Nursing or Administrator must report any alleged abuse immediately, but no later than two hours after the incident. A nursing note documented that a resident reported being raped to a driver on July 23, 2024. However, the incident was not officially reported until July 25, 2024, as indicated by the Incident Report Form. The Administrator, who serves as the abuse coordinator, acknowledged being aware of the allegation on July 23, 2024, but could not provide documentation that the initial report was sent to OSDH within the required timeframe.
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 225 citations issued within 25 miles in the last 12 months — including the 11 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 Bethany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Park | 0.7 mi | ★★★★★ | 0 | 0 |
| Windsor Hills Nursing Center | 1.5 mi | ★★★★★ | 12 | 0 |
| Heritage Manor | 1.6 mi | ★★★★★ | 15 | 0 |
| Warr Acres Nursing Center | 2.5 mi | ★★★★★ | 0 | 0 |
| North Winds Living Center | 2.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.