Gracewood Health & Rehab
6201 East 36th Street · Tulsa, OK · 74135 · 9186223430
121 certified beds For profit - Limited Liability company Chain: Bradford Montgomery
Why this verdict
- Carries CMS’s abuse warning icon.
- Staffing levels are well below research benchmarks for safe care.
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
89% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | 89% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (33 in the current record)
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Actual harm · G April 6, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 15, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E April 6, 2026 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected May 20, 2026 · Resident Rights
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Potential for harm · D April 6, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Past Non-Compliance · Quality of Life and Care
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Potential for harm · E January 14, 2025
Keep residents' personal and medical records private and confidential.
Corrected February 18, 2025 · Resident Rights
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Potential for harm · D January 14, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected February 18, 2025 · Quality of Life and Care
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Potential for harm · E January 14, 2025
Provide activities to meet all resident's needs.
Corrected February 20, 2025 · Quality of Life and Care
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Potential for harm · D January 14, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 18, 2025 · Quality of Life and Care
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Potential for harm · D January 14, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected February 25, 2025 · Quality of Life and Care
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Potential for harm · D January 14, 2025
Post nurse staffing information every day.
Corrected February 18, 2025 · Nursing and Physician Services
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Potential for harm · E January 14, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected February 20, 2025 · Pharmacy Service
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Potential for harm · D January 14, 2025
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected February 25, 2025 · Pharmacy Service
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Potential for harm · E January 14, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected February 22, 2025 · Pharmacy Service
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Potential for harm · D January 14, 2025
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected February 25, 2025 · Administration
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Potential for harm · E January 14, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected February 21, 2025 · Resident Assessment and Care Planning
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Potential for harm · D January 14, 2025
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected February 20, 2025 · Environmental
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Potential for harm · E January 14, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected February 20, 2025 · Environmental
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Potential for harm · E January 14, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected February 25, 2025 · Infection Control
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Potential for harm · F October 3, 2024 · found via complaint
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected October 25, 2024 · Administration
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Potential for harm · D November 13, 2023 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 26, 2023 · Quality of Life and Care
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Potential for harm · D September 28, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 10, 2023 · Quality of Life and Care
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Potential for harm · D August 23, 2023 · found via complaint
Provide and implement an infection prevention and control program.
Corrected September 25, 2023 · Infection Control
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Potential for harm · D May 4, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 21, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 4, 2022
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected May 21, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 4, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 21, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 4, 2022
Respond appropriately to all alleged violations.
Corrected May 21, 2022 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 375438 · certified since June 15, 2003. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.