Based on record review and interview, the facility failed to ensure grievances were received and tracked by an identified grievance official per facility policy. The ADON identified 76 residents resided at the facility.Findings: Facility's grievance binder was reviewed. The binder contained several grievances filed by Resident #23 dated 01/07/26 and 03/19/26. The grievance dated 01/07/26 had no investigation reports attached.An undated policy titled, Grievance policy and procedure, read in part, the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and actions that will be taken to correct any identified problems.On 03/24/26 at 9:30 a.m., Resident #23 stated that they had filled out multiple grievances… …
F585 citations in Oklahoma
Grievances · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oklahoma cites F585 less often than its own record predicts
0.38 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oklahoma in 2025, this is the portion that was F585.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oklahoma surveyors wrote
F585 findings written in Oklahoma, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility failed to develop a grievance policy, appoint a grievance official, and maintain documentation of the results of all grievances. These deficient practices had the potential to affect all 68 residents who currently resided in the facility.Findings included: A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2026, revealed the facility admitted Resident #21 on 06/22/2025. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. An annual MDS, with an ARD of 05/10/2026, revealed the facility admitted Resident #36 on 04/19/2019. …
Based on record review and interview it was determined the facility failed to maintain documentation for all grievances for 2020 and 2021. This had the potential to affect all 127 residents. Findings: On 5/17/21 at 1:27 p.m., the ADON (Assistant Director of Nursing) was asked for the 2020-2021 grievance log/book. She stated, I don't have a grievance log/book. At 1:40 p.m., Administrator #1 was asked for the 2020-2021 grievance log/book. She stated, We don't keep a grievance log/book .Any grievances needing to be distributed to all departments would have been shredded. At 1:45 p.m., Administrator #1 was asked if she was familiar with the Federal Regulations regarding specific aspects that need documented concerning grievances. She stated, No I am not, but I will be now.
The short window
Recent years
| Year | Share of Oklahoma citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 0.18× |
| 2024 | 0.29% | 0.47× |
| 2025 | 0.24% | 0.38× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oklahoma surveyors cite →
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