Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lakes during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and at risk for falls sustained a closed head injury after rolling out of bed during peri care. The incident occurred when a CNA provided care alone, despite the resident's care plan requiring two-person assistance. The facility's policy on resident safety was not consistently followed, leading to the accident.
A resident with severe cognitive impairment was not protected from sexual abuse when another resident was witnessed placing their hand on the resident's crotch. The incident was reported as abuse, but a specific safe survey was not conducted, and there was a delay in separating the residents.
A facility failed to update the PASARR for a resident with new diagnoses of anxiety, psychosis, and recurrent depression. Despite the facility's policy requiring coordination with the Medicaid PASARR program for mental disorders, no new screening was conducted after the initial assessment in 2018. Interviews with the MDS Coordinator and DON confirmed the oversight, acknowledging the need for a new PASARR due to the resident's serious mental health conditions.
The facility failed to develop comprehensive care plans for three residents, resulting in deficiencies in addressing their medical needs. One resident's care plan lacked documentation for IV antibiotics, another's did not address visual impairment despite broken glasses, and a third's did not include antipsychotic medication use for a psychotic disorder. MDS coordinators acknowledged these omissions.
A resident admitted with a pressure ulcer on the right heel did not receive timely wound care due to a lack of treatment orders and delayed physician notification. The admitting nurse failed to contact the physician, resulting in a three-day delay before treatment orders were obtained. The facility's policies for admission and physician notification were not followed, leading to a lapse in wound care protocol.
A resident with chronic pain and diabetes did not receive properly labeled and administered medications. The insulin label did not reflect a recent order change, and the LPN failed to clean the site before applying a new lidocaine patch, contrary to facility policy. The DON confirmed the correct procedures were not followed.
A long-term care facility failed to maintain an effective infection prevention and control program. The facility did not adhere to its Legionella water management policy, lacked proper enhanced barrier precautions for a resident with a wound, and failed to ensure hand hygiene and equipment cleaning practices. An LPN was observed not washing hands between resident interactions and using the same gloves for multiple tasks, increasing the risk of cross-contamination.
The facility failed to document the administration of the pneumococcal vaccine for two residents, despite signed consents. The facility's policy requires offering the vaccine within thirty days of admission, but there was no record of administration. The DON confirmed the lack of documentation and stated that no vaccines had been administered to these residents.
A resident was admitted with multiple health issues, including an unstageable eschar on the right heel. The admitting LPN failed to notify the physician of the wound or obtain treatment orders, contrary to facility policy. The physician was only informed days later by the ADON, highlighting a lapse in communication and adherence to procedures.
A facility failed to accurately code the MDS for a resident with spondylosis and peripheral vascular disease. An admission assessment incorrectly documented the presence of an indwelling catheter, which was later identified as a system error by an MDS coordinator. The coordinator admitted to multiple inaccuracies and the need for better attention to detail.
A resident was discharged after a respite stay without a completed discharge summary. The facility's policy requires documentation of the resident's destination, discharge details, teaching, medications, a brief summary, and who picked them up. An LPN confirmed the absence of the summary, despite a communication note indicating the resident's discharge and awareness of involved parties.
A resident with chronic respiratory failure did not receive proper oxygen care, as the facility failed to change oxygen tubing weekly and administered oxygen at an incorrect flow rate. Staff were unaware of specific orders, and the DON confirmed the protocol was not followed.
An LPN was observed leaving a treatment cart unlocked and unattended while preparing for wound care, contrary to the facility's policy requiring carts to be locked when not in use.
A resident with severe cognitive impairment and a history of elopement was able to leave the facility unsupervised, resulting in an Immediate Jeopardy situation. The resident was found at a local church with bruising after reportedly falling. The facility failed to document 1:1 supervision and did not adequately address the resident's elopement risk in their care plan. Staff interviews revealed a lack of awareness and training regarding elopement procedures, and the facility's door alarm system was ineffective.
The facility failed to implement its abuse policy for three residents, leading to deficiencies in handling allegations of abuse. A resident with cognitive impairment was involved in an incident with another resident, but the facility did not document required interviews or additional monitoring. Another resident reported rough handling during a transfer, resulting in a fracture, but the facility did not conduct a thorough investigation. The lack of documentation and adherence to policy raises concerns about resident safety.
The facility failed to report an alleged abuse incident involving two residents to APS and law enforcement. One resident with cognitive impairment allegedly slapped another resident with severe dementia. Staff were unaware or did not report the incident, and the administrator admitted to not notifying authorities, contrary to facility policy.
A resident with multiple wounds did not receive the required weekly wound assessments. Despite having a pressure ulcer and other wounds, the facility only documented complete assessments on two occasions, failing to provide consistent weekly evaluations as confirmed by the DON.
A facility failed to provide medical records within the required timeframe for a resident with multiple diagnoses, including a pressure ulcer and diabetes. The resident's legal representative requested the records, but the facility's policy allowed up to five business days, conflicting with the regulatory requirement of two working days. The records were mailed late, and the family confirmed they had not received them within the expected timeframe.
Failure to Prevent Resident Fall During Peri Care
Penalty
Summary
The facility failed to prevent a fall resulting in a closed head injury for a resident diagnosed with vascular dementia and Alzheimer's disease. The resident was dependent on staff for bed mobility, repositioning, turning, and transfers, and was at risk for falls. During peri care, the resident rolled out of bed and sustained a head injury. The incident occurred while a CNA was providing care alone, despite the resident's care plan indicating a need for total assistance. The CNA reported that the resident was slippery due to a bowel movement, and there were no bed rails to prevent the fall. The facility's policy emphasized resident safety and supervision to prevent accidents, yet the staff was not consistently following the care plan requirements for two-person assistance during peri care. Observations and interviews revealed inconsistencies in staff understanding and implementation of the required assistance level for the resident. The CNA involved in the incident was informed that the resident required only one-person assistance, contrary to the care plan and other staff practices. Additionally, there was no documentation of staff education on the need for two-person assistance following the incident.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically sexual abuse, as evidenced by an incident involving two residents. Resident #2, who had severe cognitive impairment due to dementia and senile degeneration of the brain, was involved in an incident where Resident #4 was witnessed placing their hand on Resident #2's crotch while they were sitting in the TV area. This incident was observed by Housekeeper #1, who reported that it took five to eight minutes to get help to separate the two residents. The facility's policy defines sexual abuse as any non-consensual sexual contact, and the incident was reported as abuse to the Department. The administrator, who also served as the abuse coordinator, acknowledged that the incident could be considered sexual abuse. However, it was noted that a specific safe survey related to this incident was not completed, although a safe survey for a different incident had been conducted earlier. The report highlights a lapse in the facility's response to the incident, as the immediate separation of the residents was delayed, and a specific assessment of the situation was not conducted promptly. Resident #2 was unable to answer questions regarding the situation due to their cognitive impairment, and no injury was noted.
Failure to Update PASARR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with a new diagnosis of a serious mental health condition had an updated Pre-Admission Screening and Resident Review (PASARR) completed. The resident, who had been initially assessed in 2018, was diagnosed with anxiety, psychosis, and recurrent depression after the initial PASARR was completed. Despite these new diagnoses, the facility did not conduct a new PASARR to determine if a Level Two assessment was necessary. The facility's policy requires coordination with the Medicaid PASARR program for individuals with mental disorders, but this was not adhered to in this case. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the facility was aware of the requirement to complete a PASARR upon admission and with the onset of new psychological diagnoses. Both staff members acknowledged that the resident's serious mental health diagnoses warranted a new screening, which was not conducted. The oversight was identified during a review of the resident's medical records, which documented the new diagnoses and the absence of an updated PASARR since the initial assessment in 2018.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. One resident with metabolic encephalopathy, chronic kidney disease, and a urinary tract infection required IV antibiotics and a midline or PICC placement. However, the care plan did not include documentation or interventions for the IV or antibiotic treatment, despite the resident completing their antibiotic course. The MDS coordinator acknowledged that the IV and antibiotic were not included in the care plan, which was a deviation from the norm. Another resident with anxiety disorder, essential hypertension, and impaired vision had a care plan that did not address their visual function, even though their CAA summary triggered this need. The resident reported broken glasses, which were observed to be taped and missing a lens. Additionally, a resident with a psychotic disorder and severe cognitive impairment was prescribed Seroquel for insomnia and delusions, but their care plan did not address the antipsychotic medication use or interventions for their condition. The MDS coordinator confirmed that the antipsychotic medication was not included in the care plan, despite being coded on the resident assessment.
Failure to Provide Timely Wound Care for Admitted Resident
Penalty
Summary
The facility failed to provide appropriate wound treatment for a resident admitted with a pressure ulcer. Upon admission, the resident had a right heel wound with eschar, which was documented as unstageable and measured 3 cm x 3 cm. Despite the presence of this wound, there were no documented treatment orders for the right heel at the time of admission. The resident's baseline care plan noted the wound and associated pain but did not include any specific treatment interventions for the wound. The deficiency was further compounded by the lack of timely communication with the attending physician. The admitting nurse, LPN #3, did not contact the physician to obtain treatment orders after completing the admission assessment. It was not until three days later that the ADON notified the physician and obtained the necessary treatment orders. During this period, the resident did not receive any treatment for the wound, as confirmed by the Treatment Administration Record (TAR), which showed the first treatment was administered three days post-admission. Interviews with the resident and staff revealed that the resident was aware of the untreated wound and that treatments only began a week after admission. The DON acknowledged that the facility's policies for admission and physician notification were not followed, resulting in a delay in wound care. This oversight led to the resident going without necessary treatment for three days, highlighting a significant lapse in the facility's wound care protocol.
Medication Labeling and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and administration of medications for a resident with chronic pain and type two diabetes mellitus. The insulin label for the resident did not reflect a recent change in the order, as the Lantus pen was labeled for 45 units, while the current order was for 55 units. The LPN acknowledged the discrepancy and mentioned the need to coordinate with the pharmacy to update the label. Additionally, the facility had a procedure for using a sticker to indicate changes in medication orders, but this was not applied to the resident's Lantus pen. Furthermore, the facility did not adhere to the standards of practice for administering topical medications. The LPN failed to clean the site before applying a new lidocaine patch to the resident's thigh, contrary to the facility's policy, which requires cleaning and drying the area and rotating the application site. The LPN admitted to not cleaning the area and only slightly moving the patch's location. The DON confirmed the correct procedure, which includes verifying the order, checking expiration, and cleaning the application site, was not followed.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies identified during the survey. The facility did not adhere to its water management program to prevent the growth of Legionella and other waterborne pathogens. The maintenance supervisor was unaware of the requirements outlined in the facility's Legionella policy, and there was no documentation to confirm that Legionella monitoring had been completed. This lack of awareness and documentation indicates a significant oversight in the facility's infection control measures. Additionally, the facility did not follow enhanced barrier precautions (EBP) for a resident with a wound. The resident had an unstageable wound with eschar on their right heel, and the facility's policy required the use of personal protective equipment (PPE) such as gowns and gloves during wound care. However, an LPN was observed performing wound care without wearing a gown, and there was no signage indicating the need for EBP for the resident. The Assistant Director of Nursing (ADON) acknowledged that the policy was not followed, which compromised the infection control protocols for residents with wounds. The facility also failed to ensure proper hand hygiene and equipment cleaning practices. An LPN was observed not washing or sanitizing their hands between resident interactions and using the same gloves for multiple tasks and residents. The LPN also did not clean the pulse oximeter or nebulizer canister after use, contrary to the facility's policies. These actions increased the risk of cross-contamination and infection spread among residents. The Director of Nursing (DON) confirmed that staff were expected to follow hand hygiene protocols and clean equipment after each use, highlighting a gap between policy and practice.
Failure to Document Pneumococcal Vaccine Administration
Penalty
Summary
The facility failed to provide documentation that the pneumococcal vaccine was administered to two of the five sampled residents reviewed for immunizations. According to the facility's Pneumococcal Vaccine policy, residents should be assessed for eligibility and offered the vaccine series within thirty days of admission. Resident #62 was admitted to the facility, and although the pneumococcal consent was signed on December 4, 2023, there was no documentation of the vaccine being administered. Similarly, Resident #69 was admitted, with the consent signed on May 2, 2024, but again, there was no documentation of vaccine administration. The Director of Nursing (DON) confirmed on November 21, 2024, that they could not locate any documentation indicating that either resident received the pneumococcal vaccine. The DON, who started at the facility in September of the same year, stated that they had not administered any vaccines to these residents.
Failure to Notify Physician of Wound on Admission
Penalty
Summary
The facility failed to notify the attending physician of a wound without a treatment order for one of the sampled residents with wounds. The resident was admitted with multiple diagnoses, including acute respiratory failure, Parkinson's disease, acute kidney failure, atrial fibrillation, a displaced bimalleolar fracture of the left lower leg, and a disorder of the skin and subcutaneous tissue. Upon admission, the resident's summary documented surgical wounds, bruises, skin tears/cuts, and other open lesions on the foot. A skin and wound progress note indicated the resident had an unstageable eschar on the right heel, measuring 3 cm x 3 cm, which was present upon admission. However, there was no documentation that the physician had been notified of this wound or that any treatment orders had been obtained. The admitting nurse, an LPN, acknowledged that they reviewed orders from a previous facility but did not contact the physician regarding the wound before leaving for the day. The physician was not notified until several days later when the Assistant Director of Nursing (ADON) contacted them. The Director of Nursing (DON) confirmed that it was the facility's expectation to notify the physician of any wounds upon admission and to obtain necessary treatment orders. This oversight resulted in a failure to adhere to the facility's policy for notifying physicians of clinical problems, as outlined in their guidelines and admission assessment procedures.
Inaccurate MDS Coding for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one of the sampled residents. The resident in question had diagnoses including spondylosis and peripheral vascular disease. An admission assessment documented that the resident had an indwelling catheter. However, during an interview, an MDS coordinator stated that the resident did not have a catheter and attributed the error to the system auto-populating incorrect information. The coordinator acknowledged the need for a correction and admitted that this was not the only instance of inaccurate coding, indicating a lack of attention to detail in the MDS assessments.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged after a respite stay. The resident was discharged on September 3, 2024, after staying at the facility since August 26, 2024. A communication note documented that the resident was picked up by transport to be taken home, with the resident's wife, Hospice, ADON, and PA being aware, and personal belongings and medications were given to the transport. However, there was no documentation of a discharge summary being completed. An LPN stated that they did not see the summary and explained that the facility's policy required documentation of the resident's destination, discharge details, any teaching, medications, a brief summary, who picked them up, and details of the stay.
Failure to Ensure Proper Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that oxygen tubing was changed and that oxygen was administered as ordered. The resident, who had chronic respiratory failure with hypoxia and hypercapnia, was observed using oxygen via nasal cannula at an incorrect flow rate of four liters instead of the prescribed two liters. Additionally, the oxygen tubing and humidifier bottle were not changed as per the facility's protocol, with the humidifier bottle dated from several months prior and the tubing lacking a date sticker. Staff interviews revealed inconsistencies in the understanding and implementation of oxygen administration protocols. LPNs were unaware of the specific orders for changing the tubing and did not consistently monitor the oxygen flow rate. The Director of Nursing confirmed that the facility's protocol required weekly changes of oxygen tubing and adherence to physician orders for oxygen flow rates. However, these protocols were not followed, leading to the deficiency in care for the resident.
Failure to Secure Treatment Cart
Penalty
Summary
The facility failed to ensure that treatment carts were secured when not in use, as observed during a survey on hall 500. The facility's policy, dated April 2007, mandates that all drugs and biologicals must be stored in a safe, secure, and orderly manner, with compartments containing these items locked when not in use. On November 19, 2024, at 3:30 p.m., an LPN was observed preparing to perform wound care and walked away from an unlocked treatment cart, leaving it unattended as they proceeded towards the nurses' station. The LPN returned to the cart two minutes later and acknowledged that they had left it unlocked, contrary to the facility's policy requiring carts to be locked when unattended.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment, daily wandering behaviors, and a history of elopement. The resident, who had diagnoses including mood disorder, vascular dementia, parkinsonism, and repeated falls, was found at a local church after eloping from the facility. Upon assessment, the resident had bruising on their lower extremities and knees and reported falling but not hitting their head. The resident was sent to the emergency room for evaluation and returned to the facility with no new orders. The facility's documentation revealed significant lapses in monitoring and supervision. There was no documentation of 1:1 supervision being completed by staff on the day and evening shifts following the resident's return from the hospital. The resident's care plan, which was supposed to address their wandering and exit-seeking behaviors, did not document the resident's risk for elopement or their history of elopement. Additionally, behavior monitoring records for the months leading up to the incident showed inconsistencies, with some elopement behaviors documented but not consistently monitored or addressed. Interviews with staff indicated a lack of awareness and training regarding elopement risks and procedures. Staff members were unsure of the policy for identifying residents at risk for elopement and did not receive additional education following the incident. The facility's doors were supposed to be locked with a code, but there was a delay in relocking, and the alarm was not heard by staff when the resident eloped. The facility did not have an assessment tool for elopement risk, relying instead on behavior monitoring forms, which were not effectively utilized to prevent the incident.
Failure to Implement Abuse Policy in LTC Facility
Penalty
Summary
The facility failed to implement its abuse policy for three residents, leading to deficiencies in handling allegations of abuse. Resident #5, who had moderate cognitive impairment, was involved in an incident where they allegedly slapped Resident #6, who had severe cognitive impairment due to dementia and Alzheimer's disease. The facility's policy required thorough investigations, including interviews with involved parties and witnesses, but there was no documentation of such interviews being conducted. Staff members were aware of the incident but did not witness it, and the facility did not document any additional monitoring or education for staff regarding the incident. Resident #2, with a history of osteoarthritis and fractures, reported leg pain and was found to have an acute displaced femur fracture. The resident believed they were handled roughly by staff during a transfer, but the facility did not document a thorough investigation into this allegation of abuse. The administrator acknowledged different stories about the incident but could not provide documentation of interviews or findings related to the allegation. The facility's failure to document a comprehensive investigation into the resident's claims of rough handling represents a significant oversight in adhering to their abuse policy. The facility's lack of documentation and failure to follow its abuse policy in these cases highlight deficiencies in their response to allegations of abuse. Despite the policy's requirement for prompt reporting and thorough investigation, the facility did not conduct or document necessary interviews with residents, staff, or witnesses. This lack of adherence to policy and documentation raises concerns about the facility's ability to protect residents from abuse and ensure their safety.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to Adult Protective Services (APS) and local law enforcement. Resident #5, who had a history of dysphagia following cerebral infarction and osteoporosis, was documented to have moderate cognitive impairment in June but was noted to have intact cognition by September. Resident #6, diagnosed with unspecified dementia, Alzheimer's disease, and a psychotic disorder with delusions, had severe cognitive impairment. An incident occurred where Resident #5 allegedly slapped Resident #6's hand, which was not witnessed by staff but was overheard by other residents. The facility's documentation indicated that the residents were separated, and staff were educated to monitor Resident #5 more closely. However, there was no documentation that the incident was reported to APS or law enforcement. Interviews with staff revealed a lack of awareness and action regarding the incident. CNA #1 and CNA #2 were unaware of any abuse incidents involving the two residents, while CMA #1 acknowledged awareness of the incident. LPN #1 stated that such incidents should be reported to the administrator and DON, and typically authorities would be called. The administrator and DON confirmed that APS and law enforcement were not notified. The administrator reviewed the incident report and admitted to not having a satisfactory explanation for the lack of reporting, despite the facility's policy requiring such actions.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure that wound and skin assessments were completed for a resident with multiple wounds. The resident was admitted with a pressure ulcer on the right heel, diabetes mellitus with polyneuropathy, congestive heart failure, cerebral infarction, and hemiplegia and hemiparesis. Initial documentation noted wounds on the right heel and great toe, but there was no additional documentation for the great toe. Subsequent notes on the resident's condition were not comprehensive assessments, as they lacked detailed descriptions and measurements of the wounds. The Director of Nursing, who also served as the wound nurse, confirmed that assessments should be conducted weekly, including measurements, stage, signs and symptoms of infection, drainage, and a full description. However, the only complete assessments documented were on two specific dates, with no weekly assessments recorded as required. This lack of consistent and thorough documentation of the resident's wounds and skin condition represents a deficiency in the facility's care practices.
Failure to Provide Medical Records Timely
Penalty
Summary
The facility failed to provide medical records within the required timeframe for a resident whose legal representative requested them. The resident, who had a diagnosis including a pressure ulcer, diabetes mellitus with polyneuropathy, congestive heart failure, cerebral infarction, and hemiplegia and hemiparesis, was admitted to the facility. The resident's spouse, who held power of attorney, requested the medical records on 07/30/24. However, the facility did not provide the records within the stipulated two working days. The facility's policy allowed up to five business days to fulfill such requests, which did not align with the regulatory requirement of two working days. The administrator acknowledged this discrepancy and noted that the records were sent to the corporate office and mailed out on 08/05/24, but they were unsure when the family received them. The family confirmed they had not received the records within the expected timeframe, highlighting a failure in the facility's process to comply with the regulation.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 221 citations issued within 25 miles in the last 12 months — including the 10 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Ann's Skilled Nursing And Therapy | 1.6 mi | ★★★★★ | 1 | 0 |
| The Health Center At Concordia | 1.8 mi | ★★★★★ | 0 | 0 |
| Warr Acres Nursing Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Baptist Village Of Oklahoma City | 2.1 mi | ★★★★★ | 2 | 0 |
| Bellevue Health & Rehabilitation Center | 2.7 mi | ★★★★★ | 8 | 0 |
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