Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 24th Place during CMS and state inspections, most recent first.
A nurse failed to follow a physician's order by administering double the prescribed amount of enteral nutrition via PEG tube to a resident with a history of dysphagia and esophagitis. This led to the resident experiencing coughing, vomiting, and aspiration, and subsequently being diagnosed with pneumonia after a hospital evaluation.
A resident with a PEG tube was administered twice the prescribed amount of enteral nutrition by an RN, contrary to physician orders. The resident subsequently experienced vomiting, aspiration, and was sent to the ER, where pneumonia was later confirmed. The DON verified that the RN did not adhere to the prescribed feeding protocol.
A common area used for resident activities was found cluttered with items such as concrete bags, a hospital bed, a broken recliner, a wheelchair with a bed grab bar, a cane, and a walker, all of which blocked access to a puzzle activity and created trip hazards. Facility staff, including the DON and administrator, confirmed the area was accessible to residents and did not meet safety or homelike environment standards.
A CNA in the facility was reported to have verbally and physically mistreated two residents. One resident stated that the CNA took away their urinal and was rough during care, while another resident confirmed witnessing this behavior. A third resident reported being addressed disrespectfully by the CNA. The DON confirmed these actions as verbal abuse, highlighting a failure to protect residents from abuse as per the facility's policy.
A resident's purse containing a wallet was stolen from their safe while they were showering. The resident, who was cognitively intact and diagnosed with MS, had removed the key to the lock box during the shower. A CNA, aware of the key's location, took it and stole the purse. The theft was discovered when staff attempted to retrieve the purse, and the police confirmed the CNA's involvement through a charge made at a gas station.
The facility failed to serve meals in a timely manner and frequency, with meals being served outside the 14-hour window between dinner and breakfast. Short staffing in the kitchen was cited as the reason for the delays, and observations confirmed that meal times were not adhered to.
The facility failed to inform residents that signing the binding arbitration agreement was voluntary and not a condition for admission or continued care. This was confirmed through record reviews and interviews, revealing that all residents had signed agreements without this crucial information.
The facility failed to accurately code resident assessments for two residents, leading to discrepancies in the documentation of pressure ulcers. One resident's assessment incorrectly indicated no pressure ulcers, while another's assessment inaccurately documented a stage 4 pressure ulcer.
The facility failed to provide adequate supervision and proper transferring techniques for two residents. One resident with Parkinson's Disease was left unsupervised, leading to a near-fall incident. Another resident with Rheumatoid Arthritis was improperly transferred by staff without using a gait belt, contrary to the facility's policy and the resident's care plan.
The facility failed to ensure a physician's order was in place for a resident's catheter. The resident was observed with a catheter, but no order was found in the medical records. The DON confirmed the absence of the order, and the CNO stated that facility policy requires a physician's order before providing catheter care.
The facility failed to store and label food items according to professional standards. An LPN identified undated and unlabeled rolls, biscuits, and chicken patties in the freezer, which should have been dated and labeled according to the facility's Food Storage policy. The DON identified 67 residents in the facility.
A facility failed to document the required transfer information for a resident hospitalized with heart failure and COPD. Despite policies requiring a transfer form and DNR order to accompany the resident, there was no documentation that these were provided. The resident was transferred to the emergency room after showing symptoms of distress, but the RN did not document the provision of medical information to emergency services.
Failure to Follow Physician's Order for Enteral Feeding Resulting in Aspiration
Penalty
Summary
A deficiency occurred when a nurse failed to follow a physician's order for enteral feeding for a resident with a PEG tube. The physician's order specified that the resident should receive 237 ml of Osmolite 1.5 Cal via PEG tube every four hours, with a flush of 60 ml of water before and after feeding. However, the nurse administered two containers of the formula instead of one during a feeding. This deviation from the prescribed order was confirmed by both the nurse and the Director of Nursing. The resident subsequently developed symptoms including coughing, vomiting, and aspiration, which were reported to the physician. Following the incident, the resident was sent to the emergency room for possible fluid overload and aspiration. Medical documentation indicated that the resident was diagnosed with left basilar pneumonia following a chest x-ray. The resident had a history of esophagitis, dysphagia, and traumatic hemorrhage of the cerebrum, and was cognitively intact at the time of the incident. The facility's policy required verification of physician orders for tube feedings and prompt reporting of complications, but these procedures were not followed in this case.
Failure to Follow Enteral Feeding Orders Leads to Aspiration and Hospitalization
Penalty
Summary
A registered nurse (RN) failed to follow physician's orders regarding enteral feeding for a resident with a PEG tube. The resident, who had diagnoses including esophagitis, dysphagia, and traumatic hemorrhage of the cerebrum, had a physician's order for 237 ml of Osmolite 1.5 Cal to be administered via PEG tube every four hours, with a flush of 60 ml water before and after each feeding. Despite documented training on tube feeding, the RN administered two bottles of formula instead of the ordered one bottle during a morning feeding. Following the overfeeding, the resident began coughing and vomiting, eventually aspirating on the formula. The RN notified the physician, who advised holding the next feeding and monitoring the resident. The resident was later sent to the emergency room for possible fluid overload and aspiration. A subsequent chest x-ray confirmed left basilar pneumonia. The Director of Nursing confirmed that the RN did not follow the physician's order, resulting in the adverse event.
Obstructed Common Area Creates Unsafe, Non-Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in one of three common areas observed, specifically at the North end of hall one. Observations revealed that the pathway to a resident puzzle activity was obstructed by various items, including two bags of dry sack concrete, a hospital bed without sheets, a broken recliner, a wheelchair with an empty bucket and a bed grab bar balanced across its arms, an unattended walking cane, and a red walker. These items created trip and fall hazards and blocked resident access to the ongoing puzzle activity. The facility's own policy requires a clean, sanitary, and orderly environment, but this standard was not met in the observed area. Interviews with the maintenance supervisor, DON, and administrator confirmed that the area was accessible to residents and acknowledged that the clutter and stored items posed a fall risk and did not facilitate a safe, homelike environment. All three staff members agreed that the pathway was not clear for residents and that the area did not meet the facility's standards for safety and comfort. The administrator noted that staff had been instructed not to store items in the area, but the practice continued.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by the actions of a Certified Nurse Aide (CNA #5) towards two residents. Resident #1 reported that CNA #5 took away their urinal, claiming it would spill on the bed, and was rough when changing and cleaning them, which was perceived as abusive. Additionally, Resident #1's roommate, Resident #2, corroborated this account, stating they witnessed CNA #5's mistreatment. Resident #3 also reported verbal abuse, stating that CNA #5 addressed them disrespectfully by their last name only, despite being told it was hurtful. The Director of Nursing (DON) reviewed the allegations and confirmed that the actions of CNA #5 should have been classified as verbal abuse. The DON expressed concerns about the aide's insensitivity and the inappropriate manner in which they spoke to Resident #1 and restricted their use of the urinal. The facility's policy on abuse prevention, revised in April 2021, emphasizes residents' rights to be free from abuse, neglect, and exploitation, yet these incidents indicate a failure to uphold these standards for the residents involved.
Failure to Protect Resident's Belongings from Misappropriation
Penalty
Summary
The facility failed to protect a resident's belongings from misappropriation, resulting in the theft of a purse containing a wallet from a resident's safe. The resident, who was cognitively intact and diagnosed with multiple sclerosis, reported that their credit card was stolen from a lock box in their closet while they were in the shower. The resident had kept the key to the box on a necklace, which they removed during showers. A CNA, who was aware of where the resident placed the key, entered the room during the shower and took the key, leading to the theft. The incident was discovered when the activities staff was instructed to retrieve the purse from the lock box, and it was found missing. The administrator was alerted, and the police were notified. The resident identified a charge made to their account at a nearby gas station, and a photo obtained from the gas station confirmed the CNA's involvement in the theft. The facility's failure to secure the resident's belongings and prevent unauthorized access by staff led to the misappropriation of the resident's property.
Failure to Serve Meals in a Timely Manner
Penalty
Summary
The facility failed to ensure meals were served in a timely manner and frequency for four meal services and for one resident. The documented meal times were not adhered to, resulting in meals being served outside the 14-hour window between dinner and breakfast. Specifically, breakfast was served late on multiple occasions, and lunch was served late to one resident. The cook acknowledged that meals were delayed due to short staffing in the kitchen. Observations confirmed that breakfast and lunch trays were served later than the posted meal times, and no breakfast tray was served on one occasion. The Social Services Director confirmed that meals should be served at the posted times.
Failure to Inform Residents of Voluntary Arbitration Agreement
Penalty
Summary
The facility failed to provide residents with a binding arbitration agreement that informed them or their representatives of their right not to sign the agreement as a condition of admission or continued care. This deficiency was identified through record reviews and interviews. Specifically, the medical records of three residents documented signed arbitration agreements that did not state that admission to the facility could occur without entering into the arbitration agreement. The Director of Nursing (DON) confirmed that all 67 residents in the facility had signed such agreements. The Administrator acknowledged that the facility's arbitration agreement did not explicitly state that signing was voluntary and would not affect admission.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure resident assessments were accurately coded for two residents. Resident #17, who had diagnoses including an open left ankle wound and cerebral palsy, had an Annual RAI assessment that incorrectly documented no pressure ulcers on question M0100A, despite a stage 3 pressure ulcer being present on question M0300C1. The MDS Coordinator later confirmed that question M0100A was answered incorrectly. Resident #51, diagnosed with Rheumatoid Arthritis, had a Quarterly RAI assessment that inaccurately documented a stage 4 pressure ulcer. A Pressure Ulcer Skin Conditions form and a Nurses Admission Assessment both indicated a sacral pressure wound without staging and as unstageable, respectively. The MDS Coordinator admitted uncertainty about why a stage 4 was documented and clarified that the wound was a stage 3 after consulting with the wound care nurse. An LPN also confirmed that the staging information was not accurate for the readmission date. The CNO stated that the facility's policy is to follow the RAI manual and ensure assessments are accurately completed.
Failure to Ensure Adequate Supervision and Proper Transferring Techniques
Penalty
Summary
The facility failed to ensure adequate supervision and proper transferring techniques for two residents, leading to potential accident hazards. Resident #7, diagnosed with Parkinson's Disease, was observed standing independently from a wheelchair, which then rolled back as the resident attempted to sit back down. This incident occurred despite the facility's policy on managing falls and fall risks, which mandates additional or different interventions if falls recur. The Director of Nursing (DON) acknowledged that Resident #7 should have been monitored to prevent such an incident. Resident #51, diagnosed with Rheumatoid Arthritis, was subjected to improper transferring techniques by the staff. The facility's Controlled Lift Policy mandates the use of a gait belt for resident handling, except in specific cases. However, CNA #1 and CNA #2 were observed lifting Resident #51 without using a gait belt, instead using their arms and the back of the resident's pants to transfer them. This method was contrary to the facility's policy and the resident's care plan, which required one or two staff members for transfers. The DON confirmed that a gait belt should be used for transfers without a lift and that a mechanical lift or two-person assist would be necessary if the resident could not bear weight.
Lack of Physician Order for Catheter Use
Penalty
Summary
The facility failed to ensure a physician's order was in place for the use of a catheter for one resident reviewed for catheter use. During an observation, the resident was noted to have a catheter, but a subsequent review of the Order Summary Report revealed no physician order for the catheter. The Director of Nursing (DON) confirmed that nurses are responsible for entering physician orders into the medical records and acknowledged the absence of an order for the catheter. The Chief Nursing Officer (CNO) stated that the facility's policy requires an appropriate diagnosis and a physician's order, including catheter size and change schedule, to be entered into the system before providing catheter care.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store and label food items according to professional standards for food safety. During an observation on 05/07/24 at 11:06 a.m., food items were found in the freezer undated and unlabeled. At 11:07 a.m., an LPN identified the unlabeled and undated food items as rolls, biscuits, and chicken patties. At 11:08 a.m., the LPN stated that these items should be dated and labeled. The facility's undated Food Storage policy states that all foods should be covered, labeled, and dated, and routinely monitored to ensure they are consumed by their safe use dates, frozen where applicable, or discarded. The Director of Nursing (DON) identified that 67 residents resided in the facility.
Failure to Document Transfer Information for Hospitalized Resident
Penalty
Summary
The facility failed to document the required information regarding a transfer in a resident's medical record, specifically for a resident who was hospitalized. The facility's policy mandates that a transfer form, including advanced directive information, special instructions, and any other necessary documentation, should accompany the resident to ensure a safe transition of care. Additionally, the policy requires that a photocopy of the Do Not Resuscitate (DNR) order be provided to the personnel transporting the resident to the hospital. However, in this case, there was no documentation that the resident's DNR form, advanced directive, face sheet, and orders were sent with the resident during the transfer. The resident involved had diagnoses of heart failure and COPD and had a physician order for DNR. On the day of the incident, the resident was noted to be clammy, cool to touch, confused, unsteady, and complained of numbness and abdominal pain, with a blood pressure reading of 94/78. Following a doctor's assessment, the resident was ordered to be sent to the emergency room. Although the RN stated that they provided the emergency medical services with the resident's medical information, they admitted to not documenting it. The Director of Nursing confirmed that there was no documentation that the necessary information was sent with the resident.
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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 Norman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Norman, Llc | 1.6 mi | — | 0 | 0 |
| Grace Skilled And Nursing Therapy Norman | 1.9 mi | — | 3 | 0 |
| Medical Park West Rehabilitation & Skilled Care | 2 mi | — | 1 | 0 |
| Holiday Heights Healthcare | 2.5 mi | — | 0 | 0 |
| Noble Health Care Center | 6.3 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 August 2026) and official state health department websites.