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Long Term Care Forms

Quality Improvement Resources

All Facilities

All documentation containing resident-identifying information must be redacted.

  • Covered facilities are skilled nursing facilities, nursing facilities, and dually-participating SNF/NF
  • All documentation containing resident-identifying information must be redacted
  • An IIDR can be requested for deficiencies with a scope and severity of "G" or above that lead to the imposition of a Civil Monetary Penalty (CMP) and for which notice has been provided to the nursing home that the CMP will be collected and placed in escrow
  • CMS may collect imposed Civil Monetary Penalties (CMPs) and place them in an escrow account
  • You must request the IIDR within 10 calendar days of CMS Initial Imposition Notice

Skilled Nursing Facilities/Nursing Facilities/Dually-Participating SNF/NF: IIDR Request Form 833A

LTC Facility Complaint Poster

LTC Incident Reporting ODH Form 283

Notification of Nurse Aide, Abuse, Neglect, Mistreatment or Misappropriation of Property ODH Form 718   Instructions for ODH Form 718

Tuberculosis (TB) Risk Assessment Worksheet    Evaluation of TB Risk

 

Assisted Living Centers

Assisted Living Resident Assessment Form 

Assisted Living Optional POC Form

Assisted Living Optional POC Instructions

Assisted Living Center Plan of Correction - How to Avoid Rejection

  • Lists the Common Reasons for Rejections

Assisted Living Optional Plan of Correction Customer Feedback

Nursing Homes

Notice to Facility for Authorized Electronic Monitoring Consent Form

Consent By Roommate for Authorized Electronic Monitoring Form

Contact Information:

Mailing Address:
Oklahoma State Department of Health
Long Term Care Services
123 Robert S. Kerr. Ave., Suite 1702
Oklahoma City, OK 73102-6406

Physical Address:
Oklahoma State Department of Health
Long Term Care Services
123 Robert S. Kerr Ave.
Oklahoma City, OK

Phone: (405) 426-8200
Email: LTC@health.ok.gov

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