Above 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 University Park Skilled Nursing And Therapy Memory during CMS and state inspections, most recent first.
The facility failed to complete annual competency reviews for two CNAs. One CNA was hired in 2003 and the other in 2022, but neither had documented reviews in their personnel files. The administrator was unable to provide the required documentation when requested.
A resident with a history of epilepsy and falls experienced an unwitnessed fall resulting in a closed head injury. Despite the facility's policy requiring three days of neurological checks post-fall, no documentation of these checks was found. The DON and ADON confirmed the absence of records, indicating non-compliance with the facility's fall program policy.
A facility failed to ensure sanitary conditions for a resident's oxygen concentrator filters, which were observed with moderate dust buildup. The resident, who had shortness of breath and sleep apnea, required respiratory care. Despite a policy requiring monthly cleaning, there was no order in the system to track this, and an LPN could not recall the last cleaning date.
A facility failed to document post-dialysis care for a resident with end-stage renal disease. Despite having a process in place, the required documentation was missing for several dates, as confirmed by an LPN and the DON. The issue persisted even after an inservice training was conducted.
A facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter. An LPN and the ADON were observed providing catheter care without wearing gowns, contrary to the facility's policy requiring gowns and gloves for residents with indwelling medical devices. The resident had benign prostate hyperplasia and diabetes mellitus, and a physician's order specified the need for EBP. The LPN admitted the oversight, and the DON confirmed the requirement for EBP.
A resident with dementia and a psychotic disorder left a facility through an open window and was later found by police. The resident was returned to the facility, but staff were instructed not to admit them. The RN took the resident to a motel without proper documentation or the resident's consent to discharge AMA. Discrepancies in staff accounts and documentation were noted.
A resident with dementia and a psychotic disorder, identified as high risk for elopement, managed to leave the facility through a window without triggering the alarm, which was not functioning. Nursing staff did not routinely check the alarms, and there was no documentation of regular maintenance checks. The resident was discovered missing by an LPN during a medication round, and a search was conducted without success. The incident was not documented in the clinical record, and the cause of the alarm failure was unclear.
A facility failed to maintain complete and accurate medical records for a resident with dementia and psychotic disorder who eloped. The resident threatened to leave, and a BIMS assessment showed cognitive intactness. Later, the resident was found missing, prompting a search and police notification. An LPN noted the medical record was inaccurate, highlighting deficiencies in record-keeping.
Failure to Complete Annual Competency Reviews for CNAs
Penalty
Summary
The facility failed to ensure that annual competency reviews were completed for two certified nursing assistants (CNAs) out of five staff members reviewed. CNA #3, hired on April 10, 2003, and CNA #2, hired on April 11, 2022, did not have their annual competency reviews documented in their personnel files. On March 6, 2025, the administrator was asked to provide documentation of these reviews but was unable to locate them by March 10, 2025.
Failure to Perform Post-Fall Neurological Checks
Penalty
Summary
The facility failed to perform post-fall neurological checks for a resident who experienced an unwitnessed fall, which resulted in a closed head injury, facial laceration, and cervical sprain. The resident, who had a medical history including epilepsy, a history of falling, and unspecified sequelae of cerebral infarction, was found on the floor in a prone position with a laceration to the forehead and right hand. After the incident, EMS was contacted, and the resident was transferred to the hospital. Upon discharge from the hospital, the resident returned to the facility with a diagnosis of a closed head injury. Despite the facility's policy requiring neurological checks for three days following an unwitnessed fall or head injury, there was no documentation of these checks being completed for the resident upon their return. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the absence of neurological check records for the resident, indicating a failure to adhere to the facility's fall program policy.
Failure to Maintain Sanitary Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain sanitary conditions for oxygen concentrator filters for a resident requiring respiratory care. During an observation, the oxygen concentrator filters for Resident #39 were found to have a moderate dust buildup. The facility's policy, revised in February 2020, mandates that oxygen concentrators be cleaned monthly or every four weeks, and as needed. Resident #39 had medical conditions including shortness of breath and sleep apnea, necessitating the use of an oxygen concentrator. Interviews with LPN #2 and the DON revealed that the filters were indeed dirty and required cleaning, but there was no order in the system to track the cleaning schedule. LPN #2 could not recall the last time the filters were cleaned, indicating a lapse in adherence to the facility's cleaning policy.
Failure to Document Post-Dialysis Care
Penalty
Summary
The facility failed to ensure proper documentation of post-dialysis care for a resident with end-stage renal disease. The resident was scheduled to receive dialysis three times a week, and the facility's protocol required the completion of a Dialysis Communication form, which included vital signs and other post-dialysis observations. However, the forms for several dates were missing this documentation, indicating a lapse in the facility's process for recording post-dialysis care. Interviews with an LPN revealed that the process involved obtaining the resident's weight upon return and sending the necessary paperwork with the resident to the dialysis unit. The LPN acknowledged that the documentation for the specified dates was not present in the electronic medical records and was not found in the printed documents either. The Director of Nursing was aware of the issue and had initiated an inservice training prior to the discovery of the missing documentation, but the deficiency persisted after the training date.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. During an observation, an LPN and the Assistant Director of Nursing (ADON) were seen providing catheter care to a resident without wearing gowns, which is a requirement under the facility's Infection Control and Isolation Policy. This policy, revised in March 2024, mandates the use of gowns and gloves during high-contact resident care activities for residents with indwelling medical devices, regardless of infection or colonization status. The resident in question had diagnoses of benign prostate hyperplasia and diabetes mellitus and was moderately impaired in daily decision-making. A physician's order from November 2024 specified that EBP should be used due to the resident's indwelling catheter. The LPN acknowledged the oversight, and the Director of Nursing confirmed that EBP should be used for residents with indwelling catheters.
Improper Discharge and Documentation of Resident
Penalty
Summary
The facility failed to adhere to regulatory requirements for the transfer and discharge of a resident diagnosed with dementia and a psychotic disorder. The incident began when the resident threatened to leave the facility, and a BIMS assessment confirmed the resident was cognitively intact. Despite this, the resident left the facility through an open window, and the police later found them on the side of the road. The police returned the resident to the facility, but a note on the door instructed staff not to admit the resident and to contact the RN for assistance. The RN eventually took the resident to a motel, despite the resident's refusal to sign an AMA form. The RN's actions were not accurately documented, and there was a discrepancy between the RN's account and the statements of other staff members. The LPN on duty reported that the RN instructed them to document the incident, but the LPN found the documentation to be inaccurate. Additionally, the CMA stated they did not witness the RN offering the AMA form to the resident. The RN's instructions to staff not to allow the resident back into the facility were communicated via text messages, which were later contradicted by another message instructing staff to admit the resident.
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 diagnosed with dementia and a psychotic disorder. The resident was identified as being at high risk for elopement, as documented in their care plan and an elopement risk scale. Despite this, the resident was able to open their window and leave the facility without triggering the window alarm, which was not functioning at the time. The nursing staff did not routinely monitor the functionality of the window alarms, and there was no documentation of regular testing by the maintenance team. On one occasion, a Licensed Practical Nurse (LPN) discovered the resident missing after entering their room to administer medications and finding the window open. The LPN notified other staff, and a search was conducted, but the resident could not be located. The clinical record did not document the elopement incident, and the corporate administrator could not confirm whether the alarm was disabled by the resident or was simply not functioning. This series of actions and inactions led to the deficiency in providing adequate supervision to prevent the resident's elopement.
Incomplete and Inaccurate Medical Records for Elopement Incident
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident who was reviewed for elopement. The resident, who had diagnoses of dementia and psychotic disorder, was noted in a nurse's note to have threatened to leave the facility. The note documented that the on-call physician was contacted and requested a BIMS assessment, which was completed and indicated the resident was cognitively intact. The note also mentioned that if the resident insisted on discharging, it would be against medical advice (AMA). On the same day, an LPN discovered that the resident was missing after finding the window open in the resident's room. The LPN notified other staff, searched the facility and grounds, and contacted the police and an RN who was not on duty. The RN instructed the LPN that they would enter the documentation into the resident's medical record regarding the incident. However, the LPN reviewed the nurse's note and stated it was not an accurate account of the incident, indicating a failure in maintaining accurate medical records.
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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 30 citations issued within 25 miles in the last 12 months — including the 1 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 Tahlequah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherokee County Nursing Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Sequoyah Pointe Skilled Nursing And Therapy | 1 mi | ★★★★★ | 0 | 0 |
| Fort Gibson Care & Rehab Center | 17.8 mi | ★★★★★ | 0 | 0 |
| Stilwell Nursing And Rehab | 20.6 mi | ★★★★★ | 0 | 0 |
| Eastgate Village Care & Rehab Center | 23.2 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.