No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Choctaw Nation Nursing Home

400 Southwest O Street, Antlers, OK 74523 · For profit - Limited Liability company · 72 certified beds · (580) 298-5528 Medicare & Medicaid certified

Call the home — (580) 298-5528 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609) — most recent Jun 20251 actual-harm citation$38,532 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $38,532 in federal fines (most recent 2024-02-14)
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (70%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
602 NE 2nd Street · (580) 298-3351 · Call to confirm hours
Pharmacy
Mays Plus1.3 mi
310 Elite St · (877) 631-1225 · Call to confirm hours
Grocery
321 W Main St · (580) 298-2246 · Call to confirm hours
Park
506 SW E St · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 2 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 held steady at 1 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.8%13.6%15.4%worse
Long-stay residents who lose too much weight3.8%3.3%5.4%better
Long-stay residents with a catheter left in their bladder6.8%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection7.9%2.8%2.0%worse
Long-stay residents with depressive symptoms2.7%3.4%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.0%4.7%3.3%worse
Long-stay residents whose ability to walk worsened20.5%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication6.6%25.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.6%95.3%typical
Long-stay residents with pressure ulcers6.8%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control21.8%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table20.3%17.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents rehospitalized after admission25.6%27.3%22.6%worse
Short-stay residents with an outpatient ER visit15.8%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.272.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.342.961.80better

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.

10.7%U.S. median 10.7%
Went back to hospital
0.46U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 6.7–16.610.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified85.7%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay3.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.0–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.601.02Oct 2022–Sep 2024CMS 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

0.68
RN hours/ resident / day
0.59
LPN hours/ resident / day
1.81
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.78
RN hoursweekends
70.0%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 72 beds and averages 24.9 residents a day — about 35% occupied, or roughly 47 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 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 3.04 hrs/resident/day on weekends vs 3.09 on weekdays — 2% thinner on weekends. RN hours go from 0.63 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% 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

7
deficiencies at the latest standard inspection (2025-06-19)
19
at the previous standard inspection (2024-02-14)

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.

ABCDEFGHIJKL

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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Hcited before2024-02-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 Based on observation, record review, and interview, the facility failed to assess for fall risk, update care plans related to falls, and educate staff related to resident falls for two (#1 and #11) of three residents who were reviewed for falls with major injury. Res #1 had a fall on 11/14/23 and sustained an abrasion to the head and on 12/07/23 Res #1 fell and sustained a closed head injury with a concussion. Res #11 had a fall on 04/28/23 and on 08/24/23 Res #11 had a fall resulting in a left femur fracture. No interventions were added or care plan updated after the falls for either resident. The administrator identified nine residents who have fallen in the last six months. Findings: A Falls - Evaluation and Prevention policy, dated 03/2015, read in part, .Residents should be evaluated for their fall risk: On admission/readmission to the facility, following a significant change in condition, quarterly, and following a fall .Upon admission, the nursing staff/interdisciplinary team should determine if a…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-06-19 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 there was RN coverage 8 hours/day, 7 days/week. The DON identified 27 residents resided in the facility. Findings: A PBJ Staffing Data Report, dated 01/01/25 through 03/31/25 [the second quarter of fiscal year 2025], showed the facility did not have RN coverage on 9 of the 90 days in that quarter. The dates identified on the PBJ report as not having RN coverage in January, February, and March 2025 were 01/06/25, 01/13/25, 01/14/25, 01/27/25, 02/03/25, 02/11/25, 02/12/25, 02/17/25, and 03/31/25. A facility document titled Time Detail Report, dated 01/01/25 through 03/31/25, showed there was not a registered nurse on duty on 01/06/25, 01/13/25, 01/14/25, 01/27/25, 02/03/25, 02/11/25, 02/12/25, 02/17/25, and 03/31/25. On 06/17/25 at 2:08 p.m., the regional director of operations #2 stated they had reviewed their staffing records and found the PBJ report for the facility, for the first quarter of 2025, was accurate. They stated the facility had not had an RN on duty on 01/06/25, 01/13/25, 01/14/25, 01/27/25, 02/03/25,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 a resident was not prescribed an antipsychotic medication for a diagnosis of Alzheimer's disease for 2 (#8 and #18) of 5 sampled residents reviewed for unnecessary medications. The ADON stated there were 6 residents prescribed antipsychotic medications at the facility. Findings: A facility policy titled Antipsychotic Medication Use, dated July 2022, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated. 1. A physician's medication order for Res #8, dated 06/02/25, showed the resident had an order for Quetiapine [an antipsychotic medication] 25 mg at bedtime for the diagnosis of unspecified dementia, mild, with other behavioral disturbance. On 06/17/25 at 3:49 p.m., the DON reviewed Res #8's order for Quetiapine and stated the resident was being administered and antipsychotic medication. They stated the resident did not have a diagnosis that was approved for the use of Quetiapine. They stated the resident had been admitted to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 quarterly assessments were completed in the required time frame for 4 (#6, 16, 18, and #20) of 5 sampled residents reviewed for MDS assessments. The administrator stated 27 residents at the facility required MDS assessments. Findings: A facility policy titled Resident Assessment Instrument, dated October 2010, read in part, The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; b. When there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve (12) months. 1. On 06/17/25 at 3:06 p.m., Res #6's EMR was reviewed for MDS assessments. In the MDS section of the record, a list of assessments and their status showed Res #6's quarterly assessment, dated 04/04/25, was still in progress. 2. On 06/17/25 at 3:37 p.m., Res #18's EMR was reviewed for MDS assessments. In the MDS…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 a resident was provided with a written letter of transfer prior to being transferred to a hospital for 1 (#3) of 2 sampled residents that were reviewed for hospitalizations and discharges. The DON stated 24 residents had been transferred to a hospital in the past 6 months. Findings: A facility policy titled Admissions, Transfers, and Discharges, dated October 2022, read in part, Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). A facility progress note, dated 01/12/25 at 12:45 p.m., showed the DON had assessed the vital signs of Res #3 and then sent the resident to an emergency room in the community. On 06/19/25 at 9:33 a.m., the DON was asked to explain the facility's process for sending someone to a hospital. They stated they gave clinical paperwork regarding the resident's condition and a copy of the bed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 an annual assessment had been completed in the time frame required for 1 (#12) of 5 sampled residents reviewed for MDS assessments. The administrator stated 27 residents at the facility required MDS assessments. Findings: A facility policy titled Resident Assessment Instrument, dated October 2010, read in part, The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; b. When there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve (12) months. On 06/17/25 at 3:36 p.m., Res #12's EMR was reviewed for MDS assessments. In the MDS section, a list of assessments and their status showed Res #12's annual assessment, dated 04/15/25, was still in progress. On 06/18/25 at 8:50 a.m. the administrator stated the former MDS coordinator had quit suddenly, and the facility did…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 follow infection control practices for enhanced barrier precautions for 1 (#29) of 1 sampled residents reviewed for enhanced barrier precautions. The DON identified three residents with enhanced barrier precautions. Findings: A facility policy titled Enhanced Barrier Precautions, revised March 2024, read in part, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. An undated face sheet showed resident #29 had diagnoses which included nondisplaced comminuted fracture of shaft of the right femur, encounter for attention to gastrostomy, dysphagia, aphasia, and acute respiratory infection. A physician order, dated 05/02/23, showed the resident was to receive enteral feeding tube site care twice a day. A physician…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0887 — isolated
    Educate 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

    Based on record review and interview, the facility failed to educate/offer the COVID-19 vaccination for 1 (#15) of 5 sampled residents who were reviewed for vaccinations. The administrator identified 27 residents who resided in the facility. Findings: A facility policy titled Vaccination of Residents, read in part, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated .Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations .Provision of such education shall be documented in the resident's medical record. An undated face sheet showed Resident #15 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction and an encounter for prophylactic measures. A facility form titled Preventive Health Care, showed Resident #15 did not receive the COVID-19 vaccine. On 06/18/25 at 4:09 p.m., the DON reviewed the immunization…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 food for resident meals were stored in a safe and sanitary manner. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: On 02/06/24 at 5:11 a tour of the kitchen area was conducted. A large metal bowl, covered with foil and dated with 02/04, was observed to contain raw hamburger meat, diced peppers and onions, and dried bread cubes. An unlabeled resealable plastic container with lid was observed to contain what appeared to have been raw chicken wings in sauce. A resealable plastic container, with a label documenting tuna salad with a date of 02/03 was observed. The container of tuna salad appeared to have been served out of. An undated and opened container of Hormel Thick and Easy drink was observed on the top shelf of the refrigerator. This container documented to dispose of the drink 10 days after opening. A second container of thickened drink was observed to have been opened and was undated. This container documented to dispose of 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-14 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    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 the information submitted on the PBJ was accurate. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: A document titled PBJ staffing Data Report, dated Quarter 1 2023 (October 1 - December 31) documented one date in November of 2023 with no documented RN hours and three days in December 2023 with no RN hours documented. The report documented the facility failed to have licensed nursing coverage 24 hours a day for eight days in October 2023, six days in November, and 10 days in December of 2024. On 02/13/24 at 1:34 p.m., the administrator provided documentation the facility had RN coverage for at least eight consecutive hours on the days in question. At that time, the administrator stated they did not know why the PBJ was incorrect. The administrator stated they felt it was a problem with the accounting/payroll service who entered the facility data. On 02/14/24 at 10:49 a.m., the administrator was asked to clarify the documentation they…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-14 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans were developed regarding medication for two (#11 and #19) and for skin lesions for one (#5) of fifteen residents whose care plans were reviewed. The administrator identified 25 residents who resided in the facility. Findings: 1. Res #11 had diagnoses which included dementia. A physician's order, dated 08/29/23, documented hydroxyzine 25mg 1/2 tablet twice a day. The comprehensive care plan for Res #11 did not include a care plan for use of a psychotropic (anti-anxiety) medication. On 02/14/24 at 2:57 p.m., the DON reported the medication should have been care planned. On 02/14/24 at 3:15 p.m., the MDS coordinator reported the anti-anxiety medication for Res #11 should have been care planned. 2. Res #5 had diagnoses which included rash and other nonspecific skin eruption. An annual assessment, dated 09/11/23, documented Res #5 was severely impaired in cognition, required extensive to total assistance with most ADLs, and was at risk for…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · E2024-02-14 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 residents were bathed when scheduled for three (#15, 17, and #80) of three residents who were reviewed for bathing. The administrator identified 25 resident who resided in the facility. Findings: 1. Res #15 had diagnoses which included Alzheimer's disease, difficulty walking, lack of coordination, muscle wasting/atrophy, and muscle weakness. A Bath Schedule, updated on 02/08/24, documented Res #15 is to receive a bath on Monday, Wednesday and Friday. The Nurse Assistant Daily Body Observation Form, read in part, .Complete during shower or bath for each resident scheduled . The January and February Nursing Assistant Daily Body Observation Form, and the Point of Care History, dated 01/15/24 - 02/14/24, were reviewed and documented Res #15 did not receive five baths in January and two baths in February. On 02/14/24 at 3:00 p.m., the DON reported the resident refused their showers. The DON reported the refusals were not documented in Res #15's progress notes or care plan. The DON reported no baths are scheduled 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-14 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to obtain lab tests as ordered by the physician for one (#11) of four residents whose lab orders and results were reviewed. The administrator identified 25 residents who resided in the facility. Findings: Res #11 had diagnoses which included atrial fibrillation and cerebral infarction. A Medication Regimen Review, dated 04/11/23, read in part, .The last INR available for review is from 03/01/23. Could we add monthly INR to the orders for this resident? . The physician marked, I agree with this recommendation. A progress note, dated 04/17/23 at 5:30 p.m., read in part, [Name withheld NP here reviewing pt's chart and talking with MDS coordinator concerning frequency of PT/INR. Order was changed to every two weeks until further notice. Order was written . There was no physician order written for every two week PT/INR's in the paper medical chart or the electronic health record. An Expanded DRR Report, dated 07/12/23, read in part, .INR is being drawn per progress notes (drawn on 7-3) but results are not available for review in…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-14 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 menus were followed and residents who received altered textured diets were served the same foods as the residents who received the regular diet. The DON identified two residents who received a puree diet. Findings: An undated facility policy, titled Meal Substitution, read in part, .Menu substitutions must provide equal nutritive value and must not be excessive .1. Substitutions or changes shall be noted in the menu substitution book with the reason, date, and what was substituted indicated .3. Substitutions shall be of equal nutritive value to the original menu items, i.e.: .b. Protein source for another protein source c. Vitamin A source for another Vitamin A source d. Vitamin C source for another Vitamin C source e. Caloric value shall be equivalent 4. Substitutions shall be made in an emergency situation only and not for the convenience of the department . A menu, titled Fall/Winter 2023-2024, documented the kitchen was to…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 written standards for infection control were followed to prevent the spread of infection when passing meal trays and when providing incontinent care for dependent residents. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: An undated facility policy, titled PERINEAL CARE, read in part, .1. Observe standard universal precautions or other infection control standards as approved by appropriate facility committee . An undated facility policy, titled Policies and Practices - Infection Control Policy Statement, read in part, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent ad [sic] manage transmission of disease and infections .4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where are [sic] how to find and use pertinent procedures 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-14 · tag F0944 — pattern
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to include QAPI program mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: An undated facility document, titled QAPI Plan, read in entirety, QAPI will be held Quarterly and or as needed for identified issues. On 02/14/24 at 4:06 p.m., the administrator stated the facility had not implemented QAPI training for the staff.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-14 · tag F0949 — failed to train staff on dementia and abuse — pattern
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure the staff were provided with behavioral health training consistent with the requirements and as determined by the facility assessment. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: The facility assessment was reviewed and did not document behavioral training for the staff based on the diagnoses documented in the assessment. On 02/14/24 at 4:39 p.m., the administrator stated the ombudsman came in to discuss dementia care with the staff. The administrator stated they had discussed behavioral care needs with staff but did not have any formal training documented based on the facility assessment and resident diagnoses.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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

    Based on record review and interview, the facility failed to ensure a DNR form was signed by a resident representative with the authority to make medical decisions for residents for one (#5) of 16 residents whose records were reviewed for advanced directives. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: Res #5 had diagnoses which included aphasia, dysphagia, conversion disorder with seizures, and cognitive communication deficit. An Oklahoma Do-Not-Resuscitate (DNR) Consent Form, dated 07/15/17, documented a signature of a representative for Res #5. A five day PPS assessment, dated 12/25/23, documented the resident was moderately impaired in cognitive skills for daily decision making. A review of the resident's documents did not reveal the resident had assigned a representative as a health care proxy or POA. On 02/08/24 at 11:41 a.m., the administrator stated they had contacted the representative who signed the DNR and confirmed with them they had not been delegated as a proxy or POA for Res #5. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 ABN notices were provided for two (#11 and #13) of three residents who had been discharged from skilled services and had benefit days remaining. The facility identified five residents who had been discharged from skilled services with benefit days remaining in the previous six months. Findings: Res #11 had been discharged from skilled nursing services on 12/05/23 with benefit days remaining and had remained in the facility. The facility did not provide the resident or resident representative with an ABN notice. Res #13 had been discharged from skilled nursing services on 01/11/24 with benefit days remaining and had remained in the facility. The facility did not provide the resident or resident representative with an ABN notice. On 02/14/24 at 11:12 a.m., the MDS coordinator, the staff member assigned to provide ABN and NOMNC letters and notices to residents who received skilled services, stated they did not know what an ABN notice was. On 02/14/24 at 11:13 a.m., corporate nurse #1 confirmed Res #11 and #13 had not…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure an allegation of abuse was reported within two hours to OSDH for one (#7) of six residents whose records were reviewed. The administrator identified 25 residents who resided in the facility. Findings: A review of Res #7's incident report form and investigative notes, documented an incident of verbal abuse was witnessed by staff members on 04/30/23 at approximately 5:30 p.m. The incident was not reported to OSDH until 05/01/23 at 1:17 p.m On 02/14/24 at 4:55 p.m., the administrator reported an allegation of abuse should be reported within two hours. The administrator reported an initial incident report should have been sent in when an allegation was made, but the charge nurse at the time was new and not aware of the requirements. The administrator reported the nurse who did the combined initial and final incident report should have sent OSDH an initial incident report immediately and then worked on the investigation and completed a final incident report to OSDH within the required timeframe.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    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 MDS assessments were transmitted to CMS within seven days from completion for two (Res #2 and Res #12) who were identified by CMS for MDS records over 120 days. The Long-Term Care Facility Application for Medicare and Medicaid form documented 25 residents lived in the facility. Findings: The facility EHR system was reviewed for the past 12 months and documented Res #2 and Res #12 had assessments completed every three months. On 02/14/24 at 1:42 p.m., Corporate Nurse #1 reviewed the EHR documentation for both residents and stated the failure to transmit the assessments would have most likely occurred during the time when CMS updated the MDS forms or there was an error which caused the MDS to be rejected and the facility had not followed up with a correction. They stated they would pull the transmission reports and try to identify the issues. On 02/14/24 at 1:49 p.m., the corporate nurse stated the MDS assessment for Res #2, with an ARD date of 07/08/23, had not been submitted until 12/14/23. They stated an MDS…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 a resident assessment was accurate regarding medications and falls for one (#11) of six residents whose resident assessments were reviewed. The administrator identified 25 residents who resided in the facility. Findings: Res #11 had diagnoses which included dementia and left femur fracture. A progress note, dated 04/18/23 at 7:15 a.m., documented Res #11 had a fall in their room sustaining bruising to bilateral eyes and lip and a laceration to temple region which required transfer and treatment to the local hospital emergency room. A progress note, dated 04/28/23 at 8:55 a.m., documented Res #11 slid to the floor in the shower room during transfer to wheelchair. A quarterly assessment, dated 05/21/23, did not document any falls for Res #11. Progress notes, dated 08/24/23, documented Res #11 fell in their room and sustained a left hip fracture. A physician order, dated 08/29/23, documented hydroxyzine 25mg 1/2 tablet twice a day. A physician order, dated 08/29/23, documented tramadol 50mg every six hours PRN. A…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-14 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive care plans were updated for two (#1 and #11) of six residents whose care plans were reviewed. The administrator identified six residents who falls in the last six months. Findings: A Falls - Evaluation and Prevention policy, dated 03/2015, read in part, .Review of falls immediately .have charts (computer) present for review of nurses note documentation and CP updating. Fall interventions are to be reviewed for appropriateness, to ensure that they are a new intervention, and to ensure that they have been implemented . 1. Res #1 had diagnoses which included history of CVA with left hemiparesis/wheelchair bound, muscle wasting/atropy, lack of coordination and muscle weakness. Res #1's event report, dated 11/14/23, documented Res #1 fell and sustained an abrasion to their left forehead. Res #1's hospital paperwork, documented Res #1 fell on [DATE] and sustained a closed head injury with concussion and was hospitalized until 12/13/24.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure physician's orders were written for a resident who had an indwelling urinary catheter for one (#6) of one resident reviewed for catheters and failed to ensure a resident who is incontinent of bladder received services to help prevent urinary tract infections for one (#3) of one resident reviewed for UTIs. The facility census was 25. Findings: 1. Res #6 had diagnoses which included third degree burns to female genital region and pressure ulcers to left and right buttocks. Res #6's care plan, dated 06/06/23, read in part, .Resident requires an indwelling urinary catheter related to third degree burns .Cath size Fr. (French) 18 with 30cc balloon per MD order .change catheter every month, per MD order . Res #6's physicians orders did not include orders for Res #6 to have an indwelling urinary catheter or for the indwelling urinary catheter to be changed. On 02/13/24 at 10:35 a.m., Res #6 was observed to have an indwelling foley catheter in place. On 02/14/24 at 3:05 p.m., the DON reported they change…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to document and retain daily staffing information. The administrator identified 25 residents who resided in the facility. Findings: On 02/07/24 at 11:00 a.m. and throughout the survey, a white board at the nursing station was observed to include the facility name, date, and names and titles of staff on duty. There was no documentation of the facility census or staffing hours worked. On 02/14/24 at 3:15 p.m., the DON reported they were unaware of the requirements regarding posted staffing information and the retention of staffing information.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 a physician responded to a pharmacist medication regimen review for two (#7 and #11) of five residents whose monthly medication regimen reviews were reviewed The administrator identified 25 resident who resided in the facility. Findings: The Consultant Pharmacist Reports policy, last revised on December 2019, read in part, .Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director . 1. Res #7 had diagnoses which included depression. A Medication Regimen Review, dated 11/07/23, read in part, .Current orders include Lexapro 5mg qd. State and Federal guidelines require the dosage reduction potential of this medication to be addressed at this time. Do you feel that this resident is stable enough to tolerate a trial dc of this medication at this time? There was no documented physician response to the 11/07/23…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a care plan was revised for a resident on anticoagulation (a medication to prevent blood clots) therapy for one (#7) of two residents reviewed for anticoagulation therapy. The DON reported five residents were on anticoagulants. Findings: Res #7 was admitted with diagnoses which included DVT. A physician's order, dated 11/01/22 at 4:30 p.m., read in parts .Hold Eliquis (an anticoagulant) x3 days per PA-C . The DVT care plan for Res #7 was not updated regarding the physician's order to hold Eliquis. On 01/06/22 at 11:15 a.m., the Administrator and MDS Coordinator reported the care plan should have been updated regarding the physician's order to hold Eliquis. On 01/06/22 at 11:30 a.m., the DON reported the care plan should have been updated regarding the physician's order to hold Eliquis.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — the official record, unedited, may be distressing

    Based upon record review and interview, the facility failed to ensure an anticoagulant (a medication to prevent blood clots) was held per physician's orders for one (#7) of two residents reviewed for anticoagulation therapy. The DON reported five residents were on anticoagulants. Findings: Res #7 was admitted with diagnoses which included DVT. A physician's order, dated 11/01/22 at 4:30 p.m., read in parts .Hold Eliquis (an anticoagulant) x 3 days per PA-C . The November 2022 MAR, documented Eliquis was administered twice a day and was not held per physician's orders. On 01/06/22 at 11:15 a.m., the Administrator and MDS Coordinator reported the physician's order was not noted by a nurse which caused the Eliquis to not be held. On 01/06/22 at 11:30 a.m., the DON reported the Eliquis should have been held per physician's orders.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 Based on record review, observation, and interview, the facility failed to ensure fall risk assessments were completed per the facility's policy for three (#7, 17, and #73) of three residents reviewed for falls. The DON reported 21 residents had fallen in the last 12 months. Findings: The Falls - Evaluation and Prevention policy, dated 3/2015, read in parts, .It is the policy of this facility to evaluate residents for their fall risk and develop interventions for prevention .RESIDENTS SHOULD BE EVALUATED FOR THEIR FALL RISK: On admission/readmission to the facility .Quarterly, Following a fall .Upon admission, the nursing staff/interdisciplinary team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation . Res #7 was admitted with diagnoses which included difficulty walking, muscle atrophy, and muscle weakness. A document entitled (Name withheld) Fall list documented Res #7 had five falls in 2022. There were no fall risk assessments completed for Res #7…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure oxygen tubing was changed according to physician's orders, for one (#18) of four residents reviewed for oxygen therapy. The Resident Census and Conditions of Residents, dated 01/03/23, documented five residents received oxygen therapy. Findings: Res #18 had diagnoses which included chronic pain syndrome. A physician's order, dated 07/20/22, documented in part, May use O2 at 2L via N/C PRN . A physician's order, dated 07/28/22, documented in part, Change O2 tubing out on Thursday nights . A quarterly assessment, dated 11/01/22, documented Res #18 was legally blind, required assistance with activities of daily living, and was on oxygen therapy. A care plan, last revised on 12/20/22, documented in parts .Resident requires oxygen therapy .Administer oxygen at 2l/m via NC . A monthly summary, dated 12/17/22, documented Res #18 was on oxygen therapy. On 01/03/23 at 9:40 a.m., Res #18 was observed in bed with oxygen via NC at 2L with tubing labeled 12/23/22. On 01/03/23 at 12:15 p.m., Res #18 was observed…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$38,532 in federal fines across 1 penalty.

  • $38,532 — penalty dated 2024-02-14

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 BGM ESTATE — 15 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 →

RatingThis homeChain avg
Overall 1 of 51.8-0.8 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 3 of 52.1+0.9 vs chain
Quality measures 1 of 52.5-1.5 vs chain
The other 14 homes this chain runs (chain average 1.8★, 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 / managerTypeRoleShareSince
BGM ESTATE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 12/12/2025
PHILIP MARION GREEN EXEMPT TR CU GILBERT F GREEN TROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST23%since 12/12/2025
TIFFANY SEAY EXEMPT TROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST27%since 12/12/2025
MITCHELL, KELLYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST13%since 12/12/2025
MITCHELL, MARCINDAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST13%since 12/12/2025
MITCHELL, ROBERTIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST13%since 12/12/2025
TABOR, ANGELAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST13%since 12/12/2025
BELT, MIRANDAIndividualCORPORATE OFFICERsince 12/09/2024
PITTS, JACIIndividualCORPORATE OFFICERsince 12/09/2024
TAYLOR, SANDRAIndividualCORPORATE OFFICERsince 12/27/2020
BLAN, EVELYNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/05/2021
GREER, CONNIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/10/2025
HEADY, BRITTANIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/15/2024
PETEET, GWINDAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/19/2025
ROWLAND, TEDDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/1995
STANDRIDGE, LINDAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/17/2023
GREEN, PHILIPIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 01/28/2026
ADVANCED WOUND THERAPYOrganizationADP OF THE SNFsince 11/01/2024
CHOCTAW NATION OF OKLAHOMAOrganizationADP OF THE SNFsince 02/01/2022
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 01/01/2010
MOBILE WOUND CARE LLCOrganizationADP OF THE SNFsince 01/01/2025
NS GROUP CONSULTING DIVISIONOrganizationADP OF THE SNFsince 10/22/2020
PHARMCAREOK OF DURANT INCOrganizationADP OF THE SNFsince 10/01/2024
STEIN ANCILLARY SERVICES, LLCOrganizationADP OF THE SNFsince 10/22/2020

CMS files one row per role, so the 26 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

10 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.

$2.4M
Net patient revenuemost recent cost report
+8.5%
Operating marginrevenue minus expenses
$216K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 80%Medicare 17%Other / private 2%

About 80% 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 $216K 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 2023. 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

$279per resident / day
operating cost
$8,476per month
≈ monthly operating cost
$305per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). 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

Paying with Medicaid

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.

Typical monthly cost in Oklahoma
$7,026/mo
Nursing home (semi-private)
$7,756/mo
Nursing home (private)
$6,150/mo
Assisted living

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 375372. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-19, 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.

What to do next