Gracewood Health & Rehab
6201 East 36th Street, Tulsa, OK 74135 · Tulsa County · 121 certified beds · avg 70 residents/day · certified since Jun 15, 2003
Abuse citation flag (CMS)
Part of chain: BRADFORD MONTGOMERY (11 facilities, chain avg rating 2.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Apr 6, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 15, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 6, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 6, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 6, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 6, 2026 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Apr 6, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 6, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 6, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 14, 2025 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Jan 14, 2025 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jan 14, 2025 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jan 14, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 14, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jan 14, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 14, 2025 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Jan 14, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jan 14, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 14, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jan 14, 2025 | D · Potential for harm, one-off | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Jan 14, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 14, 2025 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Jan 14, 2025 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Oct 3, 2024 | F · Potential for harm, facility-wide | The facility employed staff who were not licensed, certified, or registered as required by state law. · from a complaint |
| Nov 13, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 23, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (14 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | D |
| 2024 | 1 | 0 | F |
| 2025 | 14 | 0 | E |
| 2026 | 7 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oklahoma avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.14 | 4.58 | 3.95 | top 22% in Oklahoma; top 11% in the U.S. |
| Registered Nurse hours | 0.47 | 0.41 | 0.69 | top 32% in Oklahoma; bottom 33% in the U.S. |
| Weekend total nurse staffing | 4.89 | 4.16 | 3.50 | top 17% in Oklahoma; top 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.31 | 0.28 | 0.48 | top 29% in Oklahoma; bottom 34% in the U.S. |
| Total nursing staff turnover (%) | 76.2 | 55.5 | 45.8 | bottom 7% in Oklahoma; bottom 3% in the U.S. |
| RN turnover (%) | 80.0 | 53.6 | 42.9 | bottom 25% in Oklahoma; bottom 6% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.92, RN 0.36, weekend 3.73. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Montgomery, Bradford | Individual | 5% or Greater Direct Ownership Interest | 100% | 10/31/2015 |
| Poppell, Connie | Individual | W-2 Managing Employee | NOT APPLICABLE | 10/31/2015 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Trinity Woods, INC. | 1.3 mi | Tulsa, OK | ★★★★★ | 5/5 | |
| Emerald Care Center Tulsa | 1.6 mi | Tulsa, OK | ★☆☆☆☆ | 1/5 | |
| Southern Hills Rehabilitation Center | 1.9 mi | Tulsa, OK | ★★★☆☆ | 3/5 | |
| Oklahoma Memory Care Institute | 1.9 mi | Tulsa, OK | ★★☆☆☆ | 2/5 | |
| Tulsa Center for Rehabilitation and Healthcare | 2.5 mi | Tulsa, OK | ★★☆☆☆ | 4/5 | |
| Leisure Village Health Care Center | 2.8 mi | Tulsa, OK | ★☆☆☆☆ | 1/5 | |
| Montereau, INC. | 3.2 mi | Tulsa, OK | ★★★☆☆ | 3/5 | |
| Colonial Manor Nursing Home | 3.6 mi | Tulsa, OK | ★★★★☆ | 3/5 | |
| The Villages at Southern Hills | 3.6 mi | Tulsa, OK | ★★★★★ | 5/5 | |
| Tulsa Nursing Center | 3.7 mi | Tulsa, OK | ★★★★☆ | 3/5 | |
| Ambassador Manor Nursing Center | 4.1 mi | Tulsa, OK | ★★☆☆☆ | 2/5 | |
| The Cottage Extended Care | 4.2 mi | Tulsa, OK | ★★★☆☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 375438.