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Bartlesville Health and Rehabilitation Community

3434 Kentucky Place, Bartlesville, OK 74006 · For profit - Corporation · 119 certified beds · (918) 333-9545 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Mar 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$75,816 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

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 (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $75,816 in federal fines (most recent 2026-01-12)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
205 SE Howard Ave · (918) 333-0474 · Call to confirm hours
Pharmacy
143 SE Washington Blvd · (918) 876-4204 · Call to confirm hours
Grocery
578 SE Washington Blvd · (918) 331-0061 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
3333 E Tuxedo Blvd · (918) 333-4440

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 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 increased16.9%13.6%15.4%typical
Long-stay residents who lose too much weight6.8%3.3%5.4%worse
Long-stay residents with a catheter left in their bladder5.4%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection10.0%2.8%2.0%worse
Long-stay residents with depressive symptoms3.2%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 injury7.7%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 medication13.8%25.7%18.9%better
Long-stay residents given the seasonal flu vaccine98.6%94.6%95.3%typical
Long-stay residents with pressure ulcers3.8%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control23.9%17.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.0%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine89.1%74.1%79.4%better
Short-stay residents rehospitalized after admission21.5%27.3%22.6%typical
Short-stay residents with an outpatient ER visit9.4%16.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.812.311.67typical
Long-stay outpatient ER visits per 1,000 resident days3.092.961.80worse

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.

43.8% 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 62 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.8%U.S. median 51.5%
Got home and stayed home
13.0%U.S. median 10.7%
Went back to hospital
58.5%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 58.5% 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 53 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 SNF43.8%CMS range 35.1–55.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.0%CMS range 8.9–18.410.7%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 discharge58.5%56.6%Oct 2024–Sep 2025CMS 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 discharge45.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge58.5%50.0%Oct 2024–Sep 2025CMS 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 identified91.4%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 discharge95.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened7.1%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 hospitalization7.9%CMS range 4.4–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

0.11
RN hours/ resident / day
1.13
LPN hours/ resident / day
3.36
Aide hours/ resident / day
4.59
Total nurse hours/ resident / day
0.10
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 119 beds and averages 74.7 residents a day — about 63% occupied, or roughly 44 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 4.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.11 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.36 is at or above 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 4.10 hrs/resident/day on weekends vs 4.80 on weekdays — 15% thinner on weekends. RN hours go from 0.11 to 0.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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 (2024-12-04)
10
at the previous standard inspection (2023-08-28)

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.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2026-01-12 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure CPR was administered in accordance with the AHA standards of practice, which states the primary goal is to ensure a firm, hard surface to maximize compression depth and the facility policy for resident #6. CPR was administered in Resident #6's bed without a back board and was ineffective. On [DATE] at 5:15 p.m., the OSDH was notified and verified the existence of the IJ related to the facility's failure to implement their CPR policy and provide effective CPR to Resident #6.On [DATE] at 6:00 p.m., the administrator, DON, and ADON were notified of the IJ situation and the IJ template was provided. On [DATE] at 2:38 p.m., an acceptable plan of removal was approved by the OSDH. The plan of removal, read in part, All nursing staff on duty received immediate education on code blue procedures, crash cart policy, and the location of emergency equipment, including the crash cart and back board, all…

    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
  • Actual harm · H2023-08-28 · 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

    Based on observation, record review, and interview, the facility failed to: a. implement interventions to prevent the reoccurrence of falls; b. complete incident reports and neurological checks according to policy and procedure; and c. revise the care plan with new interventions to prevent falls for one (#23) of two sampled residents reviewed for accident hazards. Resident #23 experienced 15 falls between 08/18/22 and 07/27/23. On 09/06/22, Res #23 fell and sustained a traumatic subdural hemorrhage, laceration on the left side of their face, and left sided fifth and seventh rib fractures, resulting in the resident being admitted to the hospital ICU. On 06/12/23, the resident fell and sustained a left fractured shoulder. The Resident Census and Conditions of Residents form, dated 08/22/23, documented 60 residents resided in the facility. Findings: An undated facility policy, titled Fall Protocol, read in part, 1. Assess resident .2. Document in the nurses notes the entire incident and resident assessment in detail. 3. Notify family and physician .4. Notify DON/ADON .5. Obtain,…

    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 · E2024-12-04 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide 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 record review and interview, the facility failed to ensure pre and post dialysis patient assessments were filled out completely and routinely by staff for one (#45) of one sampled resident reviewed for dialysis care. The DON identified one resident at the facility received dialysis services. Findings: The facility was unable to provide a policy for the care of residents that received dialysis services. An admission record for Resident #45 documented they had been readmitted to the facility on [DATE]. It further documented Resident #45 had diagnoses which included stage five chronic kidney disease and dependence on renal dialysis. A quarterly resident assessment, dated 09/25/24, documented Resident #45's cognition was intact. On 12/02/24 at 1:24 p.m., Resident #45 stated the nursing staff had not been doing their vitals as they were supposed to related to their dialysis care. On 12/03/24 at 9:46 a.m., LPN #2 stated there was a binder at the nurse station that held the dialysis assessment forms. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure dietary staff wore hair nets and beard guards while preparing food for the residents. The administrator identified 74 residents routinely ate meals provided by the facility kitchen. Findings: On 12/02/24 at 8:05 a.m., cook #1 was observed preparing food without wearing a hair net or beard guard. On 12/02/24 at 8:10 a.m., cook #1 stated they should be wearing a hair net and beard guard and that the facility was out of beard guards until the truck came in. On 12/02/24 at 8:30 a.m., the dietary manager stated the dietary staff should be wearing hair nets and beard guards. On 12/03/24 at 3:08 p.m., the administrator stated dietary staff should be wearing hair nets and beard guards.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-04 · 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: a. a licensed practical nurse cleaned their hands during wound care and catheter care for one (#16) of two sampled residents reviewed for wound care and catheter care; and b. failed to maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. A resident matrix provided by the administrator documented seven residents had indwelling catheters. The DON stated 71 residents resided in the facility. Findings: A facility policy titled Water Management, dated 01/23, read in part, It is the policy of the facility to have a plan to reduce the risk of growth and spread of opportunistic pathogens including Legionnaires in the building water system .Procedure .Create the water management team .Identify and document the building description .Identify control measures .Document collection and transport methods. A facility policy titled Hand Hygiene, dated 01/31/24, read in part, Appropriate hand hygiene is essential 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-04 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a resident's representative was notified of a fall for one (#57) of one resident reviewed for notification of changes. The DON reported the facility census was 71. Findings: A facility policy titled Family Notification Policy, updated 01/2024, read in part, The facility should identify a primary contact person or POA to receive notification .Required notifications .Accidents or any injury including falls. Resident #57 had diagnoses which included dementia and weakness. A late entry nurse note, dated 09/13/24, documented Resident #57 had fallen. The note did not document the resident's representative had been contacted. On 12/04/24 at 9:37 am, LPN #1 stated they had spoken with Resident #57's representative on 09/18/24 and the representative was unaware the resident had fallen on 09/13/24. LPN #1 also stated that family should always be notified after a fall. On 12/04/24 at 1:19 p.m., the DON stated the family should have been notified of Resident #57's fall on 09/13/24.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-04 · 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

    Based on record review and interview, the facility failed to ensure the medical director and/or their representative participated in care plan development for one (#45) of 18 sampled residents whose care plans were reviewed. A Facility Listing Report, dated 12/02/24, documented 71 residents resided at the facility. Findings: A facility policy and procedure titled Policy and Procedure: Care Plans for Resident Care, dated 11/06/24, read in part, A comprehensive care plan will be developed within 7 days after the MDS has been completed. It should include measurable objectives and time frames to meet the resident's medical, nursing, mental and psychosocial needs that are identified during the MDS process. All interdisciplinary team members will help prepare this and review and revise it quarterly if a change in condition is noted. A quarterly resident assessment, dated 09/25/24, documented Resident #45's cognition was intact. A facility document titled Care Plan Conference Summary, dated 09/26/24, documented the individuals who attended the care plan meeting. The documented attendees…

    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 · D2024-12-04 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to monitor a resident after a fall for one (#57) of one resident reviewed for falls. The DON reported the facility census was 71. Findings: A facility policy titled Fall Policy and Procedures, updated 11/06/24, read in part, If a fall does occur .Assess resident .Neuro checks as necessary .Provide treatment/immediate nursing interventions as needed .Notify the family .Notify the DON/ADON .Provide continuous documentation as follows: Observed fall without head injury V/S every shift x 24 hours. Unobserved fall without head injury V/S with neuro checks every shift X 48 hours .All falls must be documented on every shift for 72 hours along with the intervention and how it is working. Resident #57 had diagnoses which included dementia and weakness. A late entry nurse note, dated 09/13/24, documented Resident #57 had fallen. The note did not document the resident's representative or the DON/ADON had been notified. It did not document if the fall was witnessed or unwitnessed. The note did not document neuro checks had been…

    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 · Dcited before2024-12-04 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 antianxiety medication was not prescribed on an as needed basis without a 14-day limit or a physician's explanation why it should be used beyond 14 days for one (#69) of five residents reviewed for unnecessary medications. The ADON reported 29 residents at the facility were prescribed psychotropic medications. Findings: A facility policy titled Antipsychotic P&P, dated 09/2014, read in part, Residents who receive antipsychotic, sedative, hypnotic, antidepressant, or any other medications prescribed to modify behavior are evaluated to determine the effectiveness of the medication for the identified problems .The use of antipsychotics should include .Use of the medication only for the duration needed, and at the lowest effective dose. Resident #69 had diagnoses which included anxiety disorder and depression. A physician order, dated 11/13/24, documented the resident was to receive alprazolam (an antianxiety medication) 0.25mg every 8 hours as needed. The physician's order did not have a stop date. A review of…

    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 · E2024-03-06 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to implement their abuse policy for screening potential employees for the prevention of abuse for three (CNA #1, CNA #7, and LPN #3) of five sampled personnel files reviewed. The administrator identified 64 residents resided in the facility. Findings: A facility policy and procedure titled Abuse, Neglect, and Exploitation, dated 10/2022, read in part, .Abuse prevention activities for the prevention of resident abuse .screening of potential employees . 1. A Provisional Employment Form and Consent and Release Form, dated 09/27/23, documented CNA #1 affirmed the condition for provisional employment related to a background check. An undated background summary, documented CNA #1 was eligible for employment. There was no documentation when CNA #1 was hired, registry checks were completed, and CNA #1 enrolled for criminal history monitoring under the facility. 2. A Provisional Employment Form and Consent and Release Form, dated 11/02/23, documented CNA #7 affirmed the condition for provisional employment related to a background…

    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 · E2024-03-06 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    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 allegations of abuse were thoroughly investigated for two (#1 and #2) of three sampled residents reviewed for abuse. The administrator identified 64 residents resided in the facility. Findings: A facility policy and procedure titled Abuse, Neglect, and Exploitation, dated 10/2022, read in part, .Abuse allegation steps .Conduct a thorough investigation . 1. Res #1 had diagnoses which included vascular dementia, communication deficit, history of falls with injury, and cerebellar stroke syndrome. A significant change assessment, dated 02/27/24, documented the resident's cognition was severely impaired. OSDH incident report forms, incident date 02/28/24, documented intital reports of an abuse allegation for Res #1 were made to OSDH on 02/29/24 at 12:32 p.m. and 1:01 p.m. It was documented suspected abuse by CNA #1 was visualized on a video monitoring device in Res #1's room on 02/28/24 at 3:30 a.m. It was documented LPN #3 reported the video appeared to show CNA #1 physically restraining Res #1. It was documented LPN #3…

    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 · D2024-03-06 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to OSDH no later than two hours after the allegation was made for one (#1) of three sampled residents reviewed for abuse. The administrator identified 64 residents resided in the facility. Findings: A facility policy and procedure titled Abuse, Neglect, and Exploitation, dated 10/2022, read in part, .Facility reporting .The facility will immediately report all alleged violations involving .abuse .as required by State law .Immediately .within two hours of occurrence . Res #1 had diagnoses which included vascular dementia, communication deficit, history of falls with injury, and cerebellar stroke syndrome. OSDH incident report forms, incident date 02/28/24, documented intital reports of an abuse allegation for Res #1 were made to OSDH on 02/29/24 at 12:32 p.m. and 1:01 p.m. It was documented suspected abuse by CNA #1 was visualized on a video monitoring device in Res #1's room on 02/28/24 at 3:30 a.m. It was documented LPN #3 reported the video appeared to show CNA #1 physically…

    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
Show the remaining 13 citations
  • Potential for harm · Fcited before2023-08-28 · 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 the kitchen was maintained to promote food safety and sanitation. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. The CDM identified all residents received services from the kitchen. Findings: On 08/22/23 at 10:18 a.m., a tour of the kitchen and dining area were conducted. The following observations were made: a. Multiple precooked pieces of chopped chicken in a plastic bag was stored in the two compartment sink. There was no water running over the bag. The meat was still partially frozen, b. Multiple pieces of raw of chicken breasts in a plastic bag were stored on the preparation surface of the Continental three door cold preparation cooler. The meat was still partially frozen. c. There was an accumulation of lint and grease on the oven hood and oven hood filters. d. There was an accumulation of grease and food on the floor and the wall behind the cook line. e. There was material peeling off of the wall behind the cook line. f. There was an…

    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 · E2023-08-28 · tag F0578 — failed to honor advance directives / code status — pattern
    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 residents' code status was accurate for two (#41 and #43) of two sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. Findings: 1. Res #41 had diagnoses which included paraplegia, dementia, respiratory failure, paranoid schizophrenia, depression, anxiety, and pain. An admission record, dated 01/04/22, documented the resident was their own responsible party. There was no documentation the resident had a POA or a legal guardian. A DNR consent form, dated 01/11/23, documented consent for DNR was signed by administrator #2 and witnessed by the DON and SSD. A physician order, dated 01/11/23, documented a DNR status for the resident. A quarterly assessment, dated 01/24/23, documented the resident's cognition was moderately impaired. There was no documentation the resident gave consent for the DNR. On 08/23/23 at 10:01 a.m., CNA #3 was asked if the resident had a POA, legal guardian, or if they were their…

    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 · E2023-08-28 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 AAT was maintained below 81 degrees F. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. Findings: Temperature reading logs were reviewed for 08/23/23. There were no documented AAT. On 08/23/23 at 4:50 p.m., a tour of hall 300 was conducted. There was a large floor fan on the hall blowing towards the nurses station. The AAT on the thermostat on the wall for was 84.6. degrees F. The AAT with a handheld thermometer was 85.2 degrees F. On 08/23/23 at 5:05 p.m., the AAT in Res #5 and Res #53's room was 85.1 degrees F. Res #53 was observed with a floor fan on their side of the room. Both residents were asked how the air temperature was in their room. Res #5 stated the temperature was good for them, but they could not have visitors due it being too hot. Res #53 stated they used a fan to circulate the air in their room. On 08/23/23 at 5:08 p.m., the AAT in Res #7 and Res #21's room was 87.6 degrees F. Res #7 was observed with a small fan…

    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 · Ecited before2023-08-28 · tag F0657 — failed to keep the care plan current — pattern
    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

    Based on record review, observation, and interview, the facility failed to ensure care plans were reviewed and revised after falls for one (#23) of 24 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 08/22/23, documented 60 residents resided in the facility. Findings: An undated facility policy titled Fall Protocol read in part: .8. Complete a new intervention on the care plan. Res #23 had diagnoses which included Alzheimer's, dementia, traumatic subdural hemorrhage, fractured left should, and history of falling. A care plan, initiated 08/13/20, documented the following interventions: a. Keep environment simple and uncluttered. b. Monitor for fatigue and other risk factors of tendency for falls. c. Respond promptly for request for toilet. d. Review resident fall assessment every three months and PRN occurrence. e. Supervise and assist resident with transfers. f. Provide activities for resident that minimize the potential for falls while providing diversion and distraction. g. Provide a safe environment with even floors;…

    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 · E2023-08-28 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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 a physician order for a blood pressure medication was accurately transcribed for one (#12) of five sampled residents reviewed for medications. The DON identified seven residents who had physician orders for BP medications with parameters. Findings: Res #12 had diagnoses which included HTN. A physician order, dated 05/12/23, documented clonidine HCL (an antiphypertensive) 0.1 mg two times a day. Hold if SBP greater than 120. The June 2023 MAR was reviewed and documented clonidine HCL was administered 43 out of 43 opportunities when SBP was greater than 120. It was documented clonidine HCL was was held three out of nine opportunities when SBP was less than 120. The July 2023 MAR was reviewed and documented clonidine HCL was administered 52 out of 52 opportunities when SBP was greater than 120. It was documented clonidine HCL was held two out of seven opportunities when SBP was less than 120. The August 2023 MAR was reviewed and documented clonidine HCL was administered 37 out of 37 opportunities when SBP was greater…

    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 · E2023-08-28 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 being monitored for side effects for the use of an anticoagulant and/or diuretic for two (#4 and #55) of five sampled residents reviewed for medications. The DON identified 19 residents who had physician orders for an anticoagulant and 28 residents who had physician orders for a diuretic. Findings: 1. Res #4 had diagnoses which included atrial fibrillation. A care plan, revised 10/19/17, documented the resident was on anticoagulant therapy. It was documented to monitor for side effects and effectiveness every shift. A physician order, dated 12/03/21, documented Xarelto (an anticoagulant) 20 mg at bedtime. The order was discontinued on 08/02/23. A physician order, dated 06/02/23, documented to monitor for anticoagulant medication. A physician order, dated 08/02/23, documented Xarelto 15 mg in the evening. There was no documentation the resident was being monitored for side effects. On 08/24/23 at 8:15 a.m., the DON was asked to provide documentation the resident was being monitored for the use of…

    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 · Ecited before2023-08-28 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 behaviors and/or side effects were monitored for the use of psychotropic medications for four (#4, 12, 17, and #55) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 40 residents received psychoactive medications. Findings: 1. Res #4 had diagnoses which included bipolar disorder and depression. Physician orders, dated 12/03/21, documented Zoloft (an antidepressant) 50 mg in the morning, and mirtazapine (an antidepressant) 30 mg at bedtime. A care plan, revised 08/05/22, documented the resident received psychotropic medications. It was documented to monitor for side effects and effectiveness every shift. It was documented to monitor for targeted behaviors. A physician order, dated 06/02/23, documented to monitor for the use of a antipsychotic medication. A physician order, dated 06/12/23, documented to monitor for the use of antianxiety medications. A physician order, dated 08/02/23, documented Seroquel (an antipsychotic)…

    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 · E2023-08-28 · 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 ensure labs were collected as ordered by the physician for two (#4 and #12) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. Findings: 1. Res #4 had diagnoses which included DM and kidney failure. A physician order, dated 02/28/20, documented CBC, CMP, and fasting lipid every 12 months starting on 04/11/20. A physician order, dated 10/12/20, documented to draw A1C every six months starting on 11/11/20. The was no documentation an A1C was collected in November 2022. There was no documentation a CBC, CMP, and fasting lipid were collected in April 2023. A physician order, dated 08/02/23, documented BMP on 08/05/23 then weekly for 30 days every Saturday. There was no documentation a BMP was collected on 08/05/23 and on Saturday 08/12/23. On 08/24/23 at 9:15 a.m., MDS Coordinator #1 and the DON were asked for documentation a A1C was collected in November 2022, a CBC, CMP, and fasting lipid were collected…

    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 · D2023-08-28 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain an informed consent prior to installation for one (#18) of one sampled resident reviewed for side rails. The ADON identified three residents had grab bars and 17 residents had side rails. Findings: An undated policy, titled Non-restrictive Device Policy and Procedure, read in part, .a candidate for a non-restrictive device the charge nurse will: a. notify the physician and obtain orders .b.once the resident has been provided a non-restrictive device the ADON will monitor that the resident is still appropriate monthly . Res #18 had diagnoses which included depression, anxiety, chronic pain, and cerebrovascular disease. An admission MDS assessment, dated 08/01/23, documented Res #18 required extensive assistance with ADLs and was dependent on staff for mobility. A care plan, dated 08/10/23, documented the resident was a high 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-12-16 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide a written notice of transfer to resident representatives for two (#34 and #44) of three residents who had transferred to acute care facilities. The Director of Nursing identified 19 resident who had been transferred to acute care facilities in the past one year. Findings: 1. Resident #34 had diagnoses which included atherosclerotic heart disease. A review of the resident's medical records found the resident had been transferred to an acute care facility six times between the dates of 02/22/21 and 12/05/21. No documentation of the resident's representative having been given a written notice for each of the transfers was observed in the resident's medical record. 2. Resident #44 had diagnoses which included dementia and metabolic encephalopathy. A review of the resident's medical records found the resident had been transferred to an acute care facility on 07/28/21. No documentation of the resident's representative having been given a written notice of the transfer was observed in the resident's medical record. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-12-16 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide a written notice of bed hold policy to resident representatives for two (#34 and #44) of three residents reviewed who had transferred to acute care facilities. The Director of Nursing identified 19 resident who had been transferred to acute care facilities in the past one year. Findings: 1. Resident #34 had diagnoses which included atherosclerotic heart disease. A review of the resident's medical records found the resident had been transferred to an acute care facility six times between the dates of 02/22/21 and 12/05/21. No documentation of the resident's representative having been given a written notice of the bed hold policy for each of the transfers was observed in the resident's medical records. 2. Resident #44 had diagnoses which included dementia and metabolic encephalopathy. A review of the resident's medical records found the resident had been transferred to an acute care facility on 07/28/21. No documentation of the resident's representative having been given a written notice of the bed hold policy 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-12-16 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record reviews the facility failed to prevent the use of unnecessary antipsychotic medications for one (#15) of five residents reviewed for the use on unnecessary medications. The Director of Nursing identified 14 residents who were prescribed antipsychotic medications. Findings: Resident #15 had diagnoses which included dementia with behavioral disturbance. An order summary report, dated 12/15/21, documented the resident's active medication orders as of 12/15/21. The report documented a physician's order for the resident to be administered a single tablet of Risperdal 0.25mg twice a day for dementia with behaviors. A black box warning that displayed in the electronic medical record copy of this report along side the Risperdal order documented risperidone [the generic name for Risperdal] was not approved for elderly patients with dementia related psychosis and carried an increased risk of death in that population. The medication administration records for 09/01/21 through 12/15/21 were reviewed. Those records documented the resident had received 180 doses of…

    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 · E2021-12-16 · tag F0887 — pattern
    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 interview and record reviews the facility failed to document if residents received education on the COVID-19 vaccines and their decision to accept or decline vaccine administration for three (#6, 12, and #54) of five residents reviewed for infection control. The Director of Nursing identified five unvaccinated residents at the facility. Findings: 1. Resident #6 had diagnoses which included dementia, atherosclerotic hear disease, and chronic kidney disease. The resident's medical record was reviewed for documentation of education given to the resident or resident representative related to COVID-19 vaccines and wether the resident did not receive the vaccine because of contraindication or refusal. No such documentation was found in the resident medical record. 2. Resident #12 had diagnoses which included Alzheimer's disease and chronic kidney disease. The resident's medical record was reviewed for documentation of education given to the resident or resident representative related to COVID-19 vaccines and wether the resident did not receive the vaccine because of…

    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

“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

$75,816 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $14,020 — penalty dated 2026-01-12
  • $61,796 — penalty dated 2023-08-28
  • Medicare payment denial — starting 2023-09-28 for 106 days

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.

Who owns this facility

Owner / managerTypeRoleShareSince
DOUT, ALEXANDERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 11/01/2012
BHRC LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 11/01/2012
FOGLE, KIMBERLYIndividualCORPORATE OFFICERsince 04/30/2023
WILKINS, TONYIndividualCORPORATE OFFICERsince 11/01/2012
DAVITO, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2004
DRIGGERS, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/08/2024
FOWLER, TAMMYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/31/2024
HOLMES, LOGANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2025
RUMSEY, KENNETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
RYAN, KRISTENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/28/2010
VACLAW, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2004
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 12/12/1996
JIM BROWN & ASSOCIATESOrganizationADP OF THE SNFsince 11/18/2025
BROWN, JAMESIndividualADP OF THE SNFsince 01/01/2004

CMS files one row per role, so the 19 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$5.9M
Net patient revenuemost recent cost report
-8.3%
Operating marginrevenue minus expenses
$30K
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 7%Other / private 24%

This home reported $30K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$276per resident / day
operating cost
$8,376per month
≈ monthly operating cost
$254per 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 375110. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-04, 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.

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