Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Highlands At Owasso during CMS and state inspections, most recent first.
A cognitively impaired resident with cardiovascular comorbidities was given another resident’s medications when a CMA, unfamiliar with the residents, relied solely on the resident’s verbal confirmation of identity instead of using proper identification methods. The resident did not receive 11 of their own ordered medications and instead was administered multiple antihypertensives and other drugs, including amlodipine, lisinopril, and labetalol, that were not prescribed for them. Shortly after the error, the resident became diaphoretic, lethargic, cyanotic, and unresponsive, with EMS documenting sinus bradycardia, shallow respirations, and initiating cardiac arrest protocol. Hospital records showed treatment for wrong-medication administration, diagnoses of hypotension, bradycardia, and asystole, and the resident was later pronounced deceased; the medical director indicated that the erroneously administered labetalol and other antihypertensives, in combination with epinephrine given by EMS, could have contributed to an acute cardiac event.
A resident with severe cognitive impairment, dependent for most ADLs and requiring a mechanical lift with two-person assistance for transfers, was improperly positioned in a lift sling by two CNAs. During a transfer from bed to chair, staff failed to secure the resident’s back far enough on the sling, leaving inadequate trunk support and causing the resident to slip from the sling, fall to the floor, and hit the head. The resident, who was on blood thinners, complained of head pain and was later found to have a small subdural hematoma requiring hospitalization, demonstrating a failure to follow the facility’s safe lifting policy and the resident’s care plan.
A resident who had been receiving furosemide 60 mg PO daily in the hospital was admitted with discharge instructions to continue that dose, but the facility’s physician order was entered as only 40 mg PO daily. The resident, who had moderate cognitive impairment and was documented as receiving a diuretic, reported the dose discrepancy, and the ADON later confirmed that the hospital discharge order specified 60 mg daily and that a nurse had mistakenly entered the lower dose.
A cognitively intact resident with a stage II pressure ulcer to the coccyx had a physician’s order for zinc oxide 20% paste to be applied topically every shift, but the medication was left unsecured at the bedside instead of in a locked compartment. Nursing documentation later showed the resident was found mixing the zinc oxide paste into their oatmeal and confirmed ingesting some of it. Facility staff acknowledged that the topical medication had been inappropriately left unattended at the bedside and could not identify who was responsible.
A resident’s guardian requested dental assessment and denture fitting, but the clinical record contained no documentation of these services despite external e-mails confirming impressions, delivery of upper and lower dentures, and later adjustment with care instructions. The resident was observed with a denture cup at bedside and reported their dentures were in the cup, while the social service director acknowledged the absence of dental documentation in the record and was unable to explain the prolonged delay before the resident ultimately received dentures.
A facility failed to follow proper infection control practices during medication administration for a resident with chronic pain syndrome and hypertension. A CMA was observed handling oxycodone with bare hands before placing it into a medication cup, contrary to protocol. Both an LPN and the ADON confirmed that medications should not be touched with bare hands.
A resident with heart failure and anxiety disorder reported that their call light had not worked for several months, requiring them to rely on their roommate for assistance. An LPN was unaware of the issue until it was demonstrated, and the maintenance supervisor admitted that the wireless call system, which required batteries, had ongoing issues with no routine testing or scheduled battery replacement.
A resident with chronic conditions experienced a delay in receiving medications due to transcription errors and communication issues between the facility and pharmacy. The resident's hospital discharge instructions for Xanax were incorrectly transcribed, and medications were not delivered until three days post-admission. Staff interviews highlighted a lack of proactive communication with the pharmacy, resulting in medication administration delays.
The facility failed to serve meals at safe and appetizing temperatures, affecting 99 residents. A resident reported meals were never hot and often improperly cooked, while another resident found the meals inedible. The dietary manager claimed temperatures were checked, but a meal cart's gauge read 100°F, and a test tray showed shrimp at 92°F, cold and flavorless. The dietary manager acknowledged the issue.
The facility failed to maintain an effective pest control program, as evidenced by the presence of roach droppings, dead roaches, and live roaches in various areas during an environmental tour. The corporate administrator noted that the exterminator visited monthly but was unsure if recommendations were reviewed, indicating a deficiency in the pest control program.
A resident with Chronic Lymphocytic Leukemia was found with a large bruise on their arm, which they could not explain. Despite the facility's policy requiring prompt reporting of injuries of unknown origin, the incident was not reported until it was brought up as an abuse allegation. The regional administrator admitted the failure to notify the incident as required.
Fatal Medication Error Due to Failure to Correctly Identify Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically failing to correctly identify a resident before administering medications. A cognitively impaired resident with a history of atherosclerotic heart disease, hyperlipidemia, hypertension, and traumatic brain injury was admitted with orders that included amlodipine 5 mg for hypertension, to be held if systolic blood pressure was less than 115 or heart rate was less than 50. A quarterly assessment documented significantly impaired cognition with a brief mental illness score of 03, use of multiple psychotropic and other medications, and no indication that the resident rejected care. Vital signs taken the morning of the incident showed a blood pressure of 147/76 and pulse of 83 beats per minute. On the morning in question, a CMA administered medications intended for the resident’s roommate to this resident after asking the resident if they were the roommate and accepting the resident’s incorrect verbal confirmation as sufficient identification. The CMA reported being unfamiliar with the residents and relied on the resident’s verbal response rather than using other identification methods such as the photo in the health record, despite the resident’s known cognitive and hearing impairments. As a result, the resident did not receive 11 medications that were prescribed for them and instead received multiple medications prescribed for the roommate, including amlodipine 10 mg, lisinopril 40 mg, and labetalol 300 mg, all ordered with parameters to hold for low systolic blood pressure and/or low heart rate. Shortly after the medication error, nursing notes documented that the resident became diaphoretic, lethargic, pale, cyanotic around the lips, with labored breathing and unresponsiveness. EMS records indicated the facility reported that the resident had been given amlodipine, aldactone, aspirin, baclofen, cyanocobalamin, fluoxetine, glimepiride, labetalol, lamotrigine, lisinopril, metformin, and potassium chloride in error, and EMS found the resident lethargic with sinus bradycardia, shallow respirations, and initiated cardiac arrest protocol. Hospital records showed the resident was treated for having been administered the wrong medications and was diagnosed with hypotension, bradycardia, and asystole, and was pronounced expired later that morning. The medical director stated that labetalol 300 mg administered in error could have caused the resident to expire and that labetalol, amlodipine, and lisinopril all lower blood pressure, and further noted that epinephrine administered by EMS in the presence of labetalol could have caused an acute cardiac event. The resident’s representative stated the resident expired as a result of the medication administration error.
Removal Plan
- Conducted a QAPI meeting where the IDT reviewed the facility’s medication administration policies and procedures to ensure they would keep residents safe
- Provided in-service education by the DON and ADON for all staff administering medications covering medication administration policies and procedures, including correct resident identification during medication pass
- Implemented bi-weekly visual audits of staff administering medications to ensure compliance with medication administration policies and procedures
- Observed staff administering medications to verify they were identifying the correct resident during medication pass
- Verified medication aide certifications
- Completed medication aide skills check-offs
- Reviewed nursing licenses
- Suspended a medication aide
- Observed and interviewed medication aides and nursing staff across multiple shifts to confirm they had the skills and knowledge to correctly identify residents during medication pass and administer medications as prescribed
Improper Mechanical Lift Sling Positioning Leads to Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a mechanical lift in accordance with its own policy and the resident’s care plan. The facility’s Safe Lifting and Movement of Residents policy required that only staff with documented training use mechanical lifts and that residents be properly positioned in slings, with enough appropriate slings available. Resident #2’s quarterly assessment documented severe cognitive impairment with a BIMS score of 5 and dependence on others for most ADLs, including positioning and transfers. The resident’s care plan required the assistance of two or more staff members and the use of a mechanical lift for transfers. On 12/06/25, during a mechanical lift transfer from bed to chair, Resident #2 slipped from the sling and fell. A nurse’s progress note documented that the resident routinely received blood thinners, complained of head pain after the fall, and was transferred to the hospital. The progress note and state reportable incident indicated that two CNAs were present, witnessed the fall, and reported that the resident hit their head on the floor. The incident report stated that the CNAs were attempting to ambulate/transfer the resident in the lift and failed to secure the resident’s back far enough on the sling per facility policies and procedures, resulting in the resident falling from the top right of the sling and hitting their head on the ground. Further description from the ADON indicated that, upon reenactment of the transfer, it was immediately apparent that the CNAs had not properly positioned the sling, leaving the resident without trunk support. Because Resident #2 could not hold themselves up while in the sling, the improper sling positioning led to the resident falling from the sling. A subsequent nurse’s progress note documented that the resident sustained a small subdural hematoma requiring hospitalization. At the time of later observation on 01/07/26, the resident was noted sitting in a recliner, dressed, with the call light in reach, but the deficiency centers on the earlier transfer event in which staff failed to properly secure and position the resident in the mechanical lift sling as required by policy and the care plan.
Incorrect Transcription of Hospital Furosemide Order
Penalty
Summary
The facility failed to ensure medications were administered as ordered when a resident did not receive the correct furosemide dose following hospital discharge. A hospital discharge medication list for Resident #16, dated 01/09/26, directed continuation of furosemide 60 mg by mouth daily, but the corresponding physician’s order entered at the facility on the same date specified only 40 mg by mouth daily. An admission assessment dated 01/16/26 documented that the resident had a BIMS score of 12, indicating moderate cognitive impairment, and was receiving a diuretic medication. On 01/22/26 at 10:00 a.m., the resident reported that they had been taking 60 mg of furosemide daily in the hospital and had only been receiving 40 mg daily since admission to the facility. At 12:20 p.m. the same day, the ADON confirmed that the hospital discharge order called for 60 mg daily, but the nurse had mistakenly entered an order for 40 mg daily. This discrepancy between the hospital discharge medication list and the facility physician’s order, along with the resident’s report and the ADON’s acknowledgment of a nurse’s entry error, demonstrates that the facility did not provide pharmaceutical services in accordance with the prescribed medication regimen for this resident.
Unsecured Topical Medication Left at Bedside and Ingested by Resident
Penalty
Summary
The deficiency involves the facility’s failure to secure and properly store medications, resulting in a cognitively intact resident having access to zinc oxide paste at the bedside. A physician’s order directed that zinc oxide 20% external paste be applied topically to the resident’s sacrum and buttocks every shift for skin integrity, and nursing documentation noted a stage II pressure ulcer on the coccyx with surrounding redness that was treated with zinc cream and a padded dressing. Despite this being a topical medication, it was left unattended at the resident’s bedside rather than stored in a locked compartment as required. A subsequent nurse’s progress note documented that when the nurse entered the resident’s room, the resident was observed mixing zinc oxide paste into their oatmeal and confirmed having eaten some of the mixture. The resident’s comprehensive assessment showed a BIMS score of 15, indicating they were cognitively intact, and noted the use of ointment or medication applied to body areas other than the feet. Facility staff, including the MDS coordinator and ADON, later acknowledged that zinc oxide paste had been left at the bedside and that it was inappropriate to leave medications unattended for this resident, and they were unable to determine which staff member had left the cream there.
Failure to Document and Timely Coordinate Denture Services
Penalty
Summary
The facility failed to provide medically appropriate dental services by not ensuring complete and timely documentation and follow-through of denture services for one resident. The resident was observed in bed with a denture cup at the bedside, and a social service progress note documented that the resident’s guardian had provided contact information and requested that the resident be assessed and fitted for dentures. However, review of the clinical record did not show that the resident had been assessed and fitted for dentures, despite this request. E-mails from the dental provider, supplied by the social service director, showed that impressions for upper and lower dentures were made, that the resident received upper and lower dentures with no adjustments initially needed, and that the dentures were later adjusted for comfort with instructions given on denture care. The resident stated their dentures were in their denture cup. The social service director, who began working at the facility months after the initial request, reported there was no documentation in the clinical record regarding these dental services, even though they found e-mail communications from the dental provider. The social service director also stated they did not know why the information was not included in the clinical record or why it took more than a year before the resident received dentures.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident diagnosed with chronic pain syndrome and hypertension. A physician's order required the resident to receive oxycodone 20 mg every 6 hours as needed for breakthrough pain. During an observation, a Certified Medication Aide (CMA) was seen administering the resident's oxycodone by punching the medication out of the card into their bare hand before placing it into a medication cup. The CMA later acknowledged that the medication should have been punched directly into the cup without being touched. Both a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) confirmed that medications should not be handled with bare hands and should be punched directly into the medication cup.
Non-Functioning Call Light System for Resident
Penalty
Summary
The facility failed to ensure the call light system was functioning for a resident with heart failure and anxiety disorder. The resident reported that their call light had not worked for several months, and they relied on their roommate to activate their call light if they needed help. During an observation, the resident pressed the button to activate their call light, but the light outside their door did not illuminate. An LPN was shown the non-functioning call light and stated they were unaware of the issue and would inform maintenance. The maintenance supervisor acknowledged that call lights had been an ongoing issue in the facility, noting that the wireless call system required batteries. They admitted that there was no routine testing of the call system or scheduled replacement of the batteries, contributing to the deficiency.
Medication Transcription and Delivery Errors
Penalty
Summary
The facility failed to accurately transcribe admission orders and acquire medications within the required timeframe for a resident with chronic obstructive pulmonary disease, depressive episodes, and dementia with mood disturbance. The hospital discharge instructions indicated that the resident was to take alprazolam (Xanax) 1mg as needed every six hours, but the facility's admission orders incorrectly documented it as a routine medication. Additionally, the medications Xanax and Nuvigil were not delivered to the facility until three days after the resident's admission, resulting in a delay in administration. Interviews with facility staff revealed a lack of communication and verification processes between the facility and the pharmacy. The Certified Medication Aide (CMA) and Licensed Practical Nurse (LPN) stated that they often did not know a medication required a written script until it was not delivered. The facility's Director of Nursing (DON) confirmed the transcription error and acknowledged the delay in medication delivery. The staff relied on the pharmacy to notify them of any issues, which led to residents not receiving medications as ordered.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve hot foods at an appealing temperature, affecting 99 residents who ate meals prepared in the kitchen. On December 11, 2024, Resident #4 reported that meals served in their room were never hot and rarely warm, with some meals being either undercooked or overcooked. Resident #6 expressed that the meals tasted bad and suspected that the kitchen staff knowingly served inedible food. The dietary manager claimed that food temperatures were checked before serving and upon delivery to the residents' hall. However, an observation of the meal cart's temperature gauge showed it reading 100 degrees Fahrenheit, despite the heating dial being set to 145 degrees Fahrenheit. A test tray revealed that the temperature of popcorn shrimp was 92 degrees Fahrenheit, with the shrimp feeling cold, chewy, and covered in damp breading, lacking flavor. The dietary manager acknowledged the issue, stating that the food was hot when it left the kitchen.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations made during an environmental tour on the 400 hall. Roach droppings and dead roaches were found along baseboards, near and under the refrigerator, on glue traps located in the corners of the room, storage drawers, and closets. Live roaches were also observed in the corners nearest the bathroom door and near the heat/air unit in rooms 412 and another unspecified room. The corporate administrator acknowledged that the exterminator visited the facility monthly but was unsure if the administrator reviewed the recommendations left on the exterminator's invoices. Despite the exterminator's responsiveness to concerns, the presence of pests indicated a deficiency in the pest control program.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident diagnosed with Chronic Lymphocytic Leukemia of B-cell type. The resident was found with a large bruise on their right arm, which they could not explain. Initially, the resident did not report any pain, but later expressed discomfort, prompting a consultation with the wound nurse and an x-ray, which showed no fractures or abnormalities. Despite these findings, the facility did not immediately report the incident as an injury of unknown origin. The facility's policy required that all injuries of unknown source be reported promptly to local, state, and federal agencies. However, the incident was only reported as an abuse allegation after a family member inquired about the bruise, and the facility realized the reporting oversight. The regional administrator acknowledged the failure to notify the incident as an injury of unknown origin, indicating a lapse in following the established reporting procedures.
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 104 citations issued within 25 miles in the last 12 months — including the 4 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 Owasso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequoyah Pointe Living Center | 0 mi | ★★★★★ | 0 | 0 |
| Baptist Village Of Owasso | 1.6 mi | ★★★★★ | 0 | 0 |
| North County Center For Nursing And Rehabilitation | 5.9 mi | ★★★★★ | 0 | 0 |
| Green Country Care Center | 7.6 mi | ★★★★★ | 1 | 1 |
| Rolling Hills Care Center | 8.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Highlands At Owasso.
100% money-back within 48 hours.
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.