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 Wolfe Living Center At Summit Ridge during CMS and state inspections, most recent first.
A resident with Alzheimer's, dementia, and severely impaired cognition was not accurately assessed for wandering behavior on the MDS, despite documentation in progress notes and an elopement risk assessment indicating wandering and elopement risk during the assessment period. The ADON confirmed the MDS coding did not reflect the resident's actual behavior.
A resident who was at risk for elopement left the facility without triggering a door alarm and was found outside by staff. Although immediate interventions such as frequent visual checks and door alarm monitoring were started, the care plan was not updated to reflect the incident or these new interventions, as confirmed by the ADON.
A facility failed to include a resident's Power of Attorney (POA) in their clinical record, despite the resident having a cognitive communication deficit and atrial fibrillation. The resident's Advance Directives Acknowledgement form indicated a POA existed, but it was not documented as required by the facility's policy. The Social Service Director confirmed the oversight and noted that the resident's family was contacted to provide the missing document.
The facility failed to provide advance beneficiary notices (ABNs) to two residents discharged with skilled days remaining. The MDS coordinator confirmed the ABNs were not signed, and the BOM admitted to not issuing them, leaving residents uninformed of potential liability for non-covered services.
The facility failed to implement its abuse policy, resulting in deficiencies related to two residents. Allegations of abuse were not thoroughly investigated, reported to the OSDH within the required timeframe, or coordinated with the QAPI program. In one case, a resident with cerebral palsy was allegedly pushed aggressively by a CNA, and in another, a resident with cerebral infarction was allegedly handled roughly. The facility did not document thorough investigations or assessments for harm, and the QAPI program did not address these issues.
A facility failed to report an abuse allegation within the required timeframe. A resident with cerebral palsy and cognitive deficits was allegedly pushed aggressively by a CNA, leading to scratches on the CNA's arm. The incident was reported to the DON immediately but not to the state agency until the next day, exceeding the two-hour reporting requirement.
A facility failed to investigate an abuse allegation involving a resident with cerebral palsy and cognitive deficits. A CNA allegedly pushed the resident aggressively, leading to scratches on the CNA's arm. The DON witnessed the incident but did not conduct a thorough investigation or safe surveys with other residents, as required by facility policy.
A resident with chronic kidney disease and osteoarthritis did not receive scheduled bathing assistance, as required for hygiene and skin health. Despite being scheduled for specific days, records showed inconsistencies, and the resident reported staff failed to assist after requests. Interviews revealed discrepancies in documentation and adherence to the bathing schedule.
A facility failed to implement wound care orders for a resident with a venous ulcer. The resident's treatment plan included Medihoney and alginate, but these were not documented as implemented. Interviews revealed confusion over the orders, with staff unable to show that the treatments were carried out. Despite some improvement in the wound, the facility did not adhere to the specified care orders, leading to a deficiency.
A facility failed to document side effect monitoring for a resident on anticoagulant therapy, despite policy requirements. The resident, with schizoaffective bipolar type and cognitive communication deficit, was prescribed Eliquis 5 mg twice daily. The ADON confirmed the absence of monitoring documentation in the resident's records.
Inaccurate MDS Coding for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when the Minimum Data Set (MDS) was not properly coded. The resident, who had diagnoses of Alzheimer's, dementia, and severely impaired cognition, was assessed on a quarterly MDS with no wandering behavior documented in section E0900 for the seven-day look-back period. However, a progress note from the same assessment reference date indicated the resident had wandered or paced three times during a shift, and an elopement risk assessment identified the resident as at risk for elopement, noting aimless or non-goal-directed wandering. Upon review, the Assistant Director of Nursing (ADON) confirmed that the MDS section E0900 was not accurately coded, as the resident had indeed exhibited wandering behavior during the look-back period.
Failure to Update Care Plan After Elopement Incident
Penalty
Summary
The facility failed to review and revise the care plan for a resident following an elopement incident. According to facility policy, comprehensive care plans are to be updated by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and with any new or changed interventions. An incident report documented that a resident was found ambulating across the parking lot after leaving the building through an ambulance door without the door alarm sounding. Immediate interventions, including 15-minute visual checks on the resident and hourly checks on door alarms, were initiated. However, the resident's care plan, which already listed a risk for elopement, was not updated to reflect the incident or the new interventions. The ADON confirmed that the care plan did not include the elopement event or the additional monitoring measures implemented after the incident.
Failure to Document Resident's Power of Attorney
Penalty
Summary
The facility failed to ensure that a resident's Power of Attorney (POA) was included in their clinical record, which is a requirement for maintaining accurate and complete documentation of advance directives. This deficiency was identified during a review of the clinical records for a resident diagnosed with cognitive communication deficit and atrial fibrillation. The resident's Advance Directives Acknowledgement form indicated that they had a POA for medical or health care decisions, but the clinical record did not contain a copy of this document. The facility's policy on Residents' Rights Regarding Treatment and Advance Directives mandates that any advance directives, including POAs, should be documented and communicated to the staff upon admission. However, the Social Service Director (SSD) confirmed that the facility did not have a copy of the resident's POA, although the resident's family was contacted to provide it. The SSD explained that during the admission process, they review advance directives with the resident or family and request a copy of the POA if one exists. The absence of the POA in the resident's clinical record indicates a lapse in following the facility's policy and ensuring that the resident's rights and preferences are documented and respected.
Failure to Provide Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide advance beneficiary notices (ABNs) to two residents who were discharged with skilled days remaining. According to the facility's policy, ABNs should be issued when services are terminated, and the beneficiary wishes to continue receiving care that is no longer considered medically necessary. However, for two residents, the facility did not provide these notices. Resident #140 was admitted on Medicare Part A services and discharged home with skilled days remaining, yet no ABN was provided. Similarly, Resident #141 was discharged home with skilled days remaining without receiving an ABN. Interviews with facility staff revealed that the MDS coordinator confirmed the ABNs for these residents were not signed, indicating they were not provided. The Business Office Manager (BOM), responsible for completing the ABNs, admitted to not issuing them, stating they were left on their desk and not attended to. This oversight resulted in the residents not being informed of their potential liability for services not covered by Medicare.
Failure to Implement Abuse Policy and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement its abuse policy effectively, resulting in several deficiencies. The policy required the prevention of abuse, neglect, and exploitation, as well as the investigation of allegations and coordination with the QAPI program. However, the facility did not conduct a complete and thorough investigation into the allegations of abuse involving two residents. The incidents were not reported to the OSDH within the required two-hour timeframe, and there was no documentation of a physical or psychosocial assessment of the residents involved. In the case of Resident #1, who had cerebral palsy, dysphagia, and cognitive communication deficit, an allegation was made that a CNA pushed the resident aggressively. The incident was not reported to the OSDH within two hours, and there was no documentation of a thorough investigation or assessment of the resident for harm. The QAPI program did not address the abuse allegations, and the facility's staff, including the DON and administrator, admitted to not following the policy requirements for reporting and investigating abuse. Similarly, for Resident #23, who had cerebral infarction and other conditions, an allegation was made that a CNA was rough during a shower. The investigation was incomplete, and the QAPI program did not address the abuse allegations. Interviews with staff revealed that the CNA was terminated, but there was no documentation of a thorough investigation or assessment of the resident. The facility's failure to follow its abuse policy and procedures led to deficiencies in handling these serious allegations.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse immediately to the state agency, as required by their policy. The policy mandates that any alleged violations involving abuse or resulting in serious bodily injury must be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but not later than two hours after the allegation is made. In this case, an allegation was made that a CNA pushed a resident aggressively to the shower, and the incident was not reported to the state agency until the following business day, exceeding the two-hour reporting requirement. The resident involved had a history of cerebral palsy, dysphagia, and cognitive communication deficit, and was dependent on staff for showers and baths. The incident occurred when the CNA reported scratches on their arm inflicted by the resident after the shower. The DON witnessed the CNA pushing the resident roughly in a wheelchair but attributed it to the resident's weight. Despite the incident being reported to the DON immediately, it was not communicated to the state agency within the required timeframe, as the DON believed the delay was justified due to the resident not being harmed.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with cerebral palsy, dysphagia, and cognitive communication deficit. The incident involved a CNA allegedly pushing the resident aggressively to the shower, which was reported on an OSDH form. The resident, who had no history of aggression or violence, stated that the CNA made them feel uncomfortable. The CNA reported scratches on their arm inflicted by the resident after the shower. Another CNA witnessed the incident and reported it to the DON, who admitted to witnessing the CNA push the resident roughly but attributed it to the resident's weight. The facility's policy required identifying and interviewing all involved persons and providing complete documentation of the investigation. However, the DON did not conduct safe surveys with other residents or complete a thorough investigation. The administrator confirmed that the DON failed to complete the necessary safe surveys or conduct an investigation. Additionally, the ADON stated there was no documentation of an investigation being conducted, indicating a failure to adhere to the facility's abuse, neglect, and exploitation policy.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident received their scheduled baths or showers, as required for maintaining proper hygiene and preventing skin issues. The resident, who had diagnoses including stage 4 chronic kidney disease and bilateral primary osteoarthritis of the knee, required supervision or touching assistance for bathing. Despite being scheduled for bathing assistance on specific days, records showed inconsistencies, with some days marked as 'not applicable' and others lacking documentation of a bath or shower. The resident expressed difficulty in receiving assistance, stating that staff failed to show up after requests for help, and believed they had not been bathed for over a week. Interviews with CNAs and the ADON revealed discrepancies in the documentation and understanding of the bathing schedule. CNAs were instructed not to use 'not applicable' in records, yet it appeared in the documentation. Staff were expected to offer bathing assistance multiple times if initially refused by a resident, but there was no clear evidence that this protocol was followed. The ADON confirmed that the resident required limited physical help and was scheduled for bathing assistance on specific days, yet the facility's records and staff actions did not align with these requirements.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with a full thickness venous ulcer on the left posterior lower leg. The resident's wound care orders, dated 03/05/25, included cleansing with wound cleanser, applying collagen powder, and using a four-layer wrap weekly and as needed. However, subsequent wound care progress notes indicated changes to the treatment plan, including the addition of Medihoney on 03/12/25 and alginate on 03/19/25, which were not documented as implemented. Interviews with LPN #2 and ADON #1 revealed that the Medihoney and alginate treatments were not carried out, and there was confusion regarding the orders, as ADON #1 mentioned a verbal instruction to use calcium alginate instead of Medihoney. The resident was observed with ace wrap dressings on their legs, and there was no documentation of the Medihoney or alginate being applied as per the wound care physician's orders. The facility's clean dressing change policy emphasized the importance of following physician's orders to decrease the potential for infection. Despite the resident's wound showing some improvement, the lack of adherence to the specified wound care orders represents a deficiency in the facility's care practices.
Lack of Side Effect Monitoring for Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure proper side effect monitoring for a resident prescribed anticoagulant therapy. Resident #22, who was admitted with diagnoses including schizoaffective bipolar type and cognitive communication deficit, was prescribed Eliquis 5 mg twice daily. Despite the facility's policy requiring systematic medication management and monitoring for adverse consequences, there was no documentation of side effect monitoring in the resident's physician orders or Treatment Administration Record (TAR). During an interview, the Assistant Director of Nursing (ADON) confirmed that side effect monitoring should be documented on the TAR for residents on anticoagulant therapy. However, it was acknowledged that such monitoring was absent for Resident #22. This oversight was identified as a deficiency in the facility's adherence to its medication monitoring policy, specifically for residents receiving anticoagulant medications.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harrah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrah Nursing Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Oak Hills Living Center | 5.6 mi | ★★★★★ | 4 | 2 |
| Mcloud Nursing Center | 9.7 mi | ★★★★★ | 0 | 0 |
| Sienna Extended Care & Rehab | 11.2 mi | ★★★★★ | 0 | 0 |
| Midwest City Post Acute & Rehab | 11.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.