Broken Bow Health and Rehab

In the surveyor’s words

From the most serious findings on record at Broken Bow Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 21, 2026

  Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (#3) of 3 sampled residents reviewed for accidents/hazards. Resident #3 exited the facility and ended up at a fast food restaurant after crossing a busy, four-lane highway. The ADON identified 62 residents resided in the facility and one resident was identified as high risk for wandering. On 05/19/26 at 12:40 p.m., an IJ situation was determined to exist related to the facility's failure to provide adequate supervision for Resident #3, who was determined to have a high risk for wandering, and had prior history of elopement. On 05/19/26 at 5:09 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. […]

• Immediate jeopardy, isolatedF755Aug 26, 2025

  On 08/21/25, an IJ situation was determined to exist related to the facilities failure to provide pharmacy services for Resident #1 in a timely manner.The facility was notified on 08/21/25 at 5:30 p.m., the Oklahoma State Department of Health was notified of the existence of an Immediate Jeopardy situation. On 08/21/25 at 5:38 p.m., the DON and administrator were notified of the existence of an IJ situation related to pharmacy services for Resident #1 . The IJ template was provided to administrator.On 08/23/25 at 9:26 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. […]

• Actual harm, isolatedF689Aug 31, 2023

  Based on observation, record review, and interview, the facility failed to ensure a resident was transferred properly to prevent a fall with major injury for one (#2) of three sampled residents who were reviewed for falls. CNA #3 transferred Res #2 without the required assistance of another staff member resulting in a fall with a fracture to Res #2's left tibula/fibula. The Resident Census and Conditions of Residents, dated 08/24/23 documented 44 residents required assistance with transfers. […]

• No harm, potential for more than minimal, widespreadF656Sep 29, 2022

  Based on observation, record review, and interview, the facility failed to develop a comprehensive person centered care plan on five (#32, 36, 38, 44 and #51) of five residents sampled for care plans. The Residents Census and Conditions of Residents documented 56 residents resided in the facility. Findings: A policy and procedure, revised 12/2016, titled Care Plans, Comprehensive Person-Centered read in part, Assessments of resident are ongoing and care plans are revised as information about the residents and residents' conditions change . 1. […]

• No harm, potential for more than minimal, widespreadF803Jun 1, 2021

  Based on observation, interview, and record review, it was determined the facility failed to ensure menus were followed for 53 of 53 residents who received their meals from the dietary department. The facility administrator identified 54 residents who resided in the facility. Findings: A week 4 menu, identified by the dietary manager (DM) as the current menu, documented the lunch meal for the day was to have been sausage cuts with sauteed onions and peppers, macaroni and cheese, mixed greens, blueberry cobbler, biscuit/margarine, and a beverage. On 05/24/21 at 11:30 AM, the residents were observed to receive a turkey and cheese slider, mixed vegetables, and a cinnamon applesauce cup. Some residents received one slider sandwich and some received two. […]