Ballard Nursing Center
201 West 5th Street, Ada, OK 74820 · For profit - Individual · 73 certified beds · (580) 436-1414 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2025-05-20)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (75%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 27.8% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.3% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.0% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 9.5% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 3.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 4.7% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 37.8% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.5% | 25.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 71.7% | 94.6% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.0% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.2% | 17.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.9% | 17.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 5.3% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 20.0% | 74.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 15.1% | 27.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.0% | 16.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.86 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.36 | 2.96 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.0%CMS range 45.5–70.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.1–13.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.5–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 73 beds and averages 59.5 residents a day — about 82% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.96 hrs/resident/day on weekends vs 2.92 on weekdays — about the same on weekends as weekdays. RN hours go from 0.41 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 75% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.
- Immediate jeopardy · J2025-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 05/20/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent elopement. Based on record review and interview, the facility failed to provide supervision for 1 (#1) of 3 sampled residents reviewed for wandering. The administrator identified 71 residents resided in the facility. Findings: An undated facility policy Elopement, read in part, 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge nurse or Director of Nursing .2. If an employee observes a resident leaving the premises, he/she should: 1. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary, and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .4. If an employee discovers that a resident is missing from the facility, he/she shall:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-08-28 · tag F0887 — widespreadEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were offered vaccines and received education related to COVID-19 immunizations, and if the vaccine was declined, the required documentation was in place for 1 (#54) of 5 sampled residents reviewed for immunizations. The administrator reported 60 residents resided in the facility. Findings:The admission assessment for Resident #54, dated 06/09/25, showed the resident was admitted to the facility on [DATE] with diagnoses which includes Congestive heart failure, diabetes mellitus, and hypertension. The assessment showed a BIMS score of 12 which indicated moderate cognitive impairment.A facility vaccination consent form dated 05/29/25, read in part, COVID-19 VACCINE CONSENT, followed by I do___ do not___ want resident to receive COVID-19 vaccine or boosters.Resident #54's consent form showed a check mark to indicate they wanted the COVID-19 vaccine. In Resident #54's medical record, there was no documentation to indicate a COVID-19 vaccine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure food service equipment was free from grease and grime. The dietary manager reported plate warming lids were used for residents who receive their meals in their rooms.Findings: An undated policy General Sanitation of Kitchen, read in part, Food and nutrition services staff will maintain the sanitation of the kitche. On 08/26/25 at 12:15 p.m., during a tour of the kitchen, the metal rack that held multiple plate warming lids were observed with visible buildup of grease and grime. There were no visible signs of the lids containing grease and grime. The residue on the metal rack was sticky to the touch and extended across all shelving levels where the lids were stored.On 08/26/25 at 12:17 p.m., the dietary manager stated the rack had not been cleaned and its proximity to the stove contributed to the accumulation of the grease and grime. The dietary manager stated the buildup of grease and grime on the metal rack was an oversight and needed to be cleaned.
- Potential for harm · D2025-08-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility to ensure a food allergy was included on the comprehensive care plan for 1 (#31) of 1 sampled resident reviewed for food allergies.The administrator reported 60 residents resided in the facility.Findings:A nutritional risk assessment, dated 05/20/24, showed Resident 31's diet was regular with an allergy to fish. A quarterly assessment, dated 08/19/25, showed Resident #31 required set-up assistance with eating.On 08/27/25 at 10:01 a.m., Resident #31's dietary card showed a food allergy to fish. An incident report, dated 05/28/25, showed the resident was accidentally given a tuna sandwich and had eaten a couple of bites before the CNA could take it back. The incident report was sent to the emergency room for evaluation due to the known fish allergy. An emergency room report, dated 05/28/25, showed the resident was not in any distress. The emergency room report showed the resident reported feeling funny and was medicated for a known food allergy.A care plan, dated 05/30/25, showed the resident has a known food allergy to fish.On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-27 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the physical environment was kept clean and maintained in good repair. The DON identified 53 residents resided in the facility. Findings: A facility policy and procedure titled Homelike Environment, revised 02/2021, read in part, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect .homelike setting. These characteristics include .clean, sanitary . On 03/25/24 at 10:49 a.m., the womens visitor/staff restroom was observed. There was black residue on the inside area of the toilet bowl. On 03/25/24 at 10:57 a.m., the shower room on hall 200 was observed. There was black residue on the floor and the wall in the working shower stall. There was black residue on the inside area of the toilet bowl. On 03/25/24 at 10:59 a.m., the resident restroom on hall 100 was observed. There was a strong urine odor. There were floor tiles missing around the toilet. There was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-27 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to conduct a thorough investigation into allegations of abuse for one (#38) of three sampled residents reviewed for abuse. The DON identified 53 residents who resided in the facility. Findings: An Abuse Policy, undated, read in parts, .Any allegation of abuse will be investigated by the Administrator and the Director of Nursing. The Administrator and the Director of Nursing will as a minimum: review the resident's medical record looking for events leading up to the incident, interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident (if cognitive ability permits), interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident if necessary, interview the resident's roommate, family members, and visitors as able and necessary, interview other residents to whom the accused employee provides care or services and review all events leading up to the incident .Witness reports will be reduced to writing with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-27 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a dialysis resident received monitoring before and after dialysis treatment and failed to ensure communication between the facility and the dialysis center for one (#13) of one sampled residents reviewed for dialysis. The DON identified one resident resided in the facility received dialysis services. Findings: Res #13 admitted on [DATE] with diagnoses which included end stage renal disease. Physician orders, dated 12/14/23, documented to obtain a weight before and after dialysis on Tuesday, Thursday, and Saturday. On 03/24/24 at 1:13 p.m., Res #13 was observed resting in their bed in their room. A white bordered adhesive dressing could be observed above the collar of their shirt on the right side of the chest below the collar bone. The resident stated the facility did not send any sort of communication form with them to dialysis. They stated there is not a form sent back with them when they return from dialysis. The resident stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-27 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure medications were administered as ordered for one (#13) of five sampled residents reviewed for unnecessary medications. The DON identified 53 residents resided in the facility. Findings: Res #13 had diagnoses which included heart failure, hypertension, and diabetes. A physician order, dated 02/09/24, documented to administer insulin aspart according to sliding scale before meals and at bedtime. A physician order, dated 02/09/24, documented to administer metoprolol tartrate 25 mg two times per day for hypertension. The order documented to hold the medication for a heart rate less than 65. A MAR for February 2024 documented the metoprolol was administered when the resident's heart rate was less than 65 five times. A MAR for February 2024 documented the 11:00 a.m. Insulin Aspart was administered greater than one hour after the scheduled time nine times. A physician order, dated 02/09/24, documented to administer Insulin Detemir 5 units twice per day. A MAR for February 2024 documented the 7:00 a.m. insulin detemir was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-27 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The DM identified 51 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: On 03/24/24 at 9:05 a.m., a tour of the kitchen was conducted. The following observations were made. a. there was lint on the ceiling vents and the ceiling around the vents, b. there was an accumulation of lint on the white floor fan, c. there were wall tiles missing behind the stove, d. there were holes and material was peeling off the wall below the three compartment sink, e. a baseboard tile was pulling away from wall near the back door, f. there were gaps and daylight was visible on the side and under the back door, g. baseboards were missing on the walls in the dish machine area, h. there was an accumulation of white residue on and in the dish machine, i. there was black residue inside of the ice machine, j. there was black residue on the floor under equipment, k. there was a box of foam cups stored on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure infection control measures were followed during fingerstick glucose monitoring for nine (#7, 13, 20, 24, 29, 33, 42, 52, and #207) of nine residents who were observed during fingerstick glucose monitoring. Corporate nurse consultant #1 identified 12 residents who received fingerstick glucose monitoring. Findings: An Obtaining a Fingerstick Glucose Level policy, dated October 2010, read in parts, .Wear clean gloves .Wash the selected fingertip, especially the side of the finger, with warm water and soap .clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice .Remove gloves . Wash hands . On 03/25/24 at 11:15 a.m., LPN #2 was observed performing fingerstick glucose monitoring. The following observations were made: At 11:21 a.m., LPN #2 washed hands with soap and water, donned gloves, and cleansed the top of the medication cart with a disinfectant wipe. They removed two glucometers from the medication cart and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-27 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to educate, offer, and screen residents for eligibility to receive the pneumococcal vaccination for one (#34) and failed to educate, offer, and screen residents for eligibility to receive the influenza vaccination for one (#37) of five sampled residents reviewed for immunizations. The DON identified 53 residents who resided in the facility. Findings: A Pneumococcal Vaccine policy, revised April 2012, read in parts, .Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission in not conducted prior to admission . Before receiving the Pneumovax, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine .Provision of such education shall be documented in the resident's medical record .Pneumococcal vaccinations will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician approved pneumococcal vaccination protocol…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · D2024-03-27 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident had a physician order to self-administer medications for one (#37) of one sampled resident reviewed for self-administration of medications. Corporate Nurse Consultant #1 identified there were no residents with physician orders to self-administer medications. Findings: Res #37 had diagnoses which included depression. A physician order, dated 01/24/24, documented trazadone HCL (antidepressant medication) 100 mg tablet by mouth at bedtime. There was no documentation the resident had physician orders to self-administer medications. An admission assessment, dated 01/31/24, documented the resident's cognition was moderately impaired. On 03/24/24 at 10:19 a.m., there was a round white tablet in a clear medicine cup observed on the resident's over the bed table. The resident stated the tablet in the cup was on their table after they returned to their room after breakfast. They stated they did not know what the tablet was or how it got there. On 03/24/24 at 10:26 a.m., LPN #1 was asked if the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure call lights accommodated residents needs for two (#10 and #37) of two sampled residents reviewed for accommodation of needs. The DON identified 53 residents resided in the facility. Findings: 1. Res #10 had diagnoses which included RA and type 2 diabetes mellitus. An admission assessment, dated 03/15/24, documented the resident's cognition was moderately impaired. It was documented the resident had impairment on both sides of their upper extremities. On 03/24/24 at 11:24 a.m., the resident stated they had to hold down the button on their call light to keep the call light activated. They stated they had their roommate activate their call light when needed. They stated their roommates call light was one where you pushed and pulled out the button. On 03/25/24 at 12:06 p.m., CNA #1 was asked what type of call lights the facility used. They stated they had the ones where you pushed the button down and the call light stayed on until the button was pushed up. They stated they did have a few call lights where you had to hold…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's code status was accurate for one (#21) of one sampled resident reviewed for advance directives. The DON identified 53 residents resided in the facility. Findings: Res #21 had diagnoses which included COPD, HTN, major depressive disorder, hyperlipidemia, osteoarthritis, PTSD, and chronic pain. A DNR Order Acceptance or Declination Report, dated [DATE], documented there was a copy of the resident's DNR order in their chart in the facility. A DNR consent form, dated [DATE], documented the residents gave consent for DNR. A physician order, dated [DATE], documented CPR. An admission assessment, dated [DATE], documented the resident's cognition was intact. On [DATE] at 10:07 a.m., the resident was asked about their code status. They stated they had signed a DNR and it should be on file with the facility. They stated they did not want CPR. On [DATE] at 10:23 a.m., LPN #2 was asked how staff determined what was a residents' code status if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to update the care plan related to hospice services for one (#17) of two sampled resident reviewed for hospice services. The DON identified 12 residents who received hospice services. Findings: Res #17 had diagnoses which included Alzheimer's disease, dementia, and congestive heart failure. A physician order, dated 10/31/23, documented to admit to hospice services related to a diagnosis of congestive heart failure. A significant change assessment, dated 11/10/23, documented the resident was severely cognitively impaired, required partial to moderate assistance with most ADLs, and received hospice services. A care plan, initiated 03/24/24, documented coordinated services between facility and hospice for end-of-life care. All interventions related to hospice care documented an initiation date of 03/24/24. On 03/26/24 at 1:17 p.m., MDS coordinator #1 stated the resident's care plan was not updated to include hospice services when the resident was admitted to hospice in October of 2023 but should have been. They stated the care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to complete a discharge summary that included a recapitulation of the resident's stay for one (#55) of three sampled residents reviewed for discharge. The DON identified 53 residents resided in the facility. Findings: Res #55 discharged from the facility on 03/01/24. A Discharge summary, dated [DATE], did not document a diagnosis on discharge or a summary of the course of treatment in the facility. On 03/26/24 at 1:32 p.m., corp. nurse consult #1 stated the nurse should have filled out the recapitulation of stay portion of the discharge summary.
- Potential for harm · Dcited before2024-03-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure an antianxiety medication was monitored for effectiveness and side effects for one (#13) of five sampled residents reviewed for unnecessary medications. The DON identified 53 residents resided in the facility. Res #13 had diagnoses which included anxiety. A physician order, dated 12/07/23, documented to administer buspirone 10 mg three times per day for anxiety. A physician order, dated 03/24/24, documented to monitor side effects of antianxiety medications. On 03/26/24 at 9:04 a.m., corporate nurse consultant #1 was asked to provide documentation of side effect monitoring from 12/07/23 to 03/24/24. On 03/26/24 at 9:21 a.m., corporate nurse consultant #1 stated there was no documentation of side effect monitoring from December to March.
- Potential for harm · Ecited before2023-02-09 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a specific condition and diagnosis was documented, based on a comprehensive assessment/evaluation, for the use of a psychotropic medication for one (#16) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented eight residents who received an antipsychotic medication. A facility policy, Psychotropic Medication Use, dated July 2022, documented in parts, .Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record .Consideration of the use of any psychotropic medication is based on comprehensive review of the resident .This includes evaluation of the resident's signs and symptoms in order to identify underlying causes . Resident #16 was admitted to the facility on [DATE] with diagnoses which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2025-05-20
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to IHS MANAGEMENT CONSULTANTS — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.6 | +0.4 vs chain |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 3 of 5 | 2.2 | +0.8 vs chain |
The other 4 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| IHS HOLDING INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/05/1997 |
| REED, BART | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 100% | since 05/05/1997 |
| PHILLIPS, JEANETTE | Individual | W-2 MANAGING EMPLOYEE | — | since 07/29/2019 |
| IHS MANAGEMENT CONSULTANTS INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/29/2019 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $198K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375263. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.