Hillcrest Manor Nursing Center
1210 South 6th Street, Blackwell, OK 74631 · For profit - Limited Liability company · 137 certified beds · (580) 363-3244 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has citations for mishandling residents’ money or property (F0567, F0568, F0570)
- it has 2 actual-harm citations
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $46,898 in federal fines (most recent 2025-04-04)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.2% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.4% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 7.4% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.2% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.6% | 3.4% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 14.2% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.4% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 28.6% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.4% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 9.1% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.3% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 65.6% | 74.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 18.5% | 27.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 32.6% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.81 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 7.45 | 2.96 | 1.80 | worse |
‡ 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.
54.4% 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 53 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.4%CMS range 41.8–65.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.8%CMS range 7.9–15.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | 82.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 2.8–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 137 beds and averages 51.7 residents a day — about 38% occupied, or roughly 85 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 2.96 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.74 hrs/resident/day on weekends vs 3.05 on weekdays — 10% thinner on weekends. RN hours go from 0.40 to 0.27 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2025-04-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's care plan was updated to include an intervention to prevent an identified pattern of falls for 1 (#39) of 2 sampled residents reviewed for accidents. The DON stated 54 residents at the facility had care plans. Findings: A facility policy titled Care Plans, Comprehensive Person-Centered, dated December 2016, read in part, The Interdisciplinary Team (IDT), in conjunction with the resident and/or their family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. A progress note, dated 08/12/24 at 2:30 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 09/25/24 at 11:34 p.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 11/06/24 at 3:26 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 12/20/24 at 3:35 a.m., showed Res #39 had fallen while…
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.
- Actual harm · Gcited before2025-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure staff provided supervision to prevent falls which resulted in a fracture for 1 (#39) of 2 sampled residents who were reviewed for accidents. The DON stated 54 residents resided at the facility. Findings: A facility policy titled, Fall and Fall Risk, Managing, dated March 2018, read in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. A progress note, dated 08/12/24 at 2:30 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 11/06/24 at 3:26 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 12/20/24 at 3:35 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 12/25/24 at 3:55 a.m., showed Res #39 had fallen while attempting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a CMA provided supervision to prevent a resident from falling for 1 (#2) of 3 sampled residents reviewed for falls. The ADON stated 55 residents resided in the facility. Findings: A facility policy titled Falls and Fall Risk, Managing, dated March 2018, read in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A minimum date set 5-day scheduled assessment, dated 05/01/25, showed in Section C Res #2 had a brief interview for mental status score of 15 (score indicated the resident's cognition was intact). The assessment further showed in Section GG, Res #2 required the assistance of a staff member who would physically support the resident and perform more than half of the physical effort to transfer to and from toileting. A nursing progress note, dated 05/13/25 at 3:30 p.m., showed Res #2 had been found by registered nurse #2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-04 · tag F0554 — widespreadAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, records review, and interview, the facility failed to ensure a resident who self-administered their medication had been assessed for the ability to safely administer to do so for 1 (#13) of 9 sampled residents observed during medication administration observations. The DON stated one resident had self-administered medication at the facility. Findings: On 04/03/25 at 12:49 p.m., RN #1 was observed pre-setting an injector of insulin for Res #13. RN #1 was observed entering the resident's room and handing the insulin injector to the resident who raised their blouse, pushed the injector against their abdomen and pushed the button to release the insulin. The resident did not look to check the dose set on the injector prior to administering. The resident then handed the injector back to RN #1 and the RN departed the room. A policy titled Self-Administration of Medications, dated December 2016, read in part, As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-04 · tag F0623 — patternProvide 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 record review and interview, the facility failed to ensure a resident was provided a written notice of transfer prior to being transferred to a hospital for 1 (#33) of 2 sampled residents reviewed for hospitalizations. The DON stated 54 residents resided in the facility. Findings: A progress note, dated 02/15/25 at 9:51 a.m., showed the facility initiated a transfer to a hospital for Res #13. A progress note, dated 03/16/25 at 12:36 p.m., showed the facility initiated a transfer to a hospital for Res #13. On 04/04/25 at 11:58 a.m., LPN #3 stated they had been on duty on 02/15/25 and was the nurse who transferred Res #33 to a hospital that day. When asked about what documentation was sent with the resident they stated that such items as code status, orders and face sheet. LPN #3 stated they had not heard of a written notice of transfer or that it was required to be given to a resident when they go to a hospital. They stated they had never sent such a notice with a resident. On 04/04/25 at 12:01 p.m., the DON stated when they had sent residents to a hospital they would send…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-04 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure: a. a psychotropic medication had an appropriate diagnosis for 1 (#50), and b. the physician addressed a GDR for 1 (#39) of 5 residents sampled for unnecessary medications. The DON reported nine residents received antipsychotic medications. Findings: A facility policy titled Antipsychotic Medication Use, dated December 2016, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 1. A medication administration record for Res #50, dated 04/01/25 through 04/30/25, showed they had diagnoses which included dementia and delusional disorder. A Medicare five-day assessment, dated 02/14/25, showed Res #50 had a BIMS score of 12, which was indicative of a moderate impairment for daily decision making. The assessment also showed Resident #50 was receiving antipsychotic medication on a routine basis. A physician's order, dated 02/07/25, showed Res #50 was to receive risperidone (an antipsychotic medication) 0.5 mg by mouth daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-04 · tag F0636 — isolatedAssess 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive assessment contained accurate health care information for 1 (#4) of 24 sampled residents reviewed for comprehensive assessments. The DON stated 54 residents resided at the facility. Findings: A facility policy titled Certifying Accuracy of the Resident Assessment, dated November 2019, showed that each assessment must be accurate. An MDS annual assessment for Res #4, dated 01/08/25, showed in Section N0415 the resident was taking antipsychotic medications. Section N0450 of the same assessment showed the resident had not received antipsychotic medications. Res #4's medication administration record (MAR) for the month of January 2025, showed the resident had been administered the antipsychotic medication Latuda each of the seven days prior to the date of the MDS annual assessment, dated 01/08/25. On 04/03/25 at 8:07 a.m., Corp. VP #1 stated they had reviewed Res. #4's annual MDS assessment dated [DATE] and the resident's January…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-04 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident assessments were completed and submitted to Centers for Medicare and Medicaid Services for 1 (#21) of 19 sampled residents who were reviewed for resident assessments. The DON identified 54 residents resided in the facility. Findings: A Discharge summary, dated [DATE] at 2:18 p.m., showed Resident #21 was discharged from the facility on 10/25/24. The electronic health record showed the last assessment completed was a quarterly assessment, dated 10/25/24. The electronic health record did not show a discharge assessment had been completed on 10/25/24. 04/02/25 at 1:31 p.m., Corporate Vice-President of Operations #1 stated a quarterly assessment had been completed instead of a discharge assessment by mistake.
- Potential for harm · Dcited before2025-04-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 as scheduled for 1 (#1) of 3 residents reviewed for assistance with ADL's. The DON identified 54 residents who resided in the facility. Findings: An undated policy titled Activities of Daily Living (ADLs), Supporting, read in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. A quarterly assessment, dated 01/29/25, showed resident #1 had a BIMS score of 15 which is indicative of independence for daily decision making and they required moderate assistance with bathing. Shower sheets from 02/01/25 through 04/03/25 showed out of 18 opportunities, Resident #1 did not have a shower documented on 02/08/25, 02/18/25, 02/22/24, 02/25/25, 03/04/25, 03/08/25, or 04/01/25. On 04/03/25 at 10:18 a.m., Resident #1 stated they were supposed to receive a bath twice a week on Tuesday and Saturday, but sometimes they do not get a bath. Resident #1 also stated when they asked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-04 · tag F0770 — failed to provide lab services — isolatedProvide 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 completed as ordered by the physician for 1 (#24) of 6 sampled residents whose labs were reviewed. The DON reported 54 residents resided in the facility. Findings: A care plan, initiated 06/06/24 showed Resident #24 had diagnoses which included heart failure and hypertension. A quarterly assessment, dated 03/20/25, showed Resident #24 had a BIMS score of 13, which was indicative of no impairment for daily decision making. A health status note, dated 03/19/25 at 5:42 p.m., showed the physician was notified Resident #24 was complaining of a cough and congestion. The note also showed the physician ordered guaifenesin (an expectorant) 15 mg every four hours as needed and a test for RSV. A review of Resident #24's health record did not show a physician order for an RSV test on 03/19/25 or results of an RSV test collected on 03/19/25. On 04/03/25 at 4:02 p.m., LPN #1 stated when a nurse received an order for lab work they should collect the sample and put an order in the computer. They also stated if the lab was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-04 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, recored review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for 1 (#7) of 3 sampled residents reviewed for enhanced barrier precautions. The DON reported 14 residents were on enhanced barrier precautions. Findings: On 04/02/25 at 2:19 p.m., RN #1 and CNA #2 were observed providing wound care to Resident #7. RN #1 was observed wearing a gown and CNA #2 was not observed wearing a gown. On 04/02/25 at 2:30 p.m., CNA #2 was observed providing incontinent care to resident #7. They were not wearing a gown. A medication administration record, dated 04/25, showed Resident #7 had diagnoses which included neuromuscular dysfunction of the bladder and stage IV pressure ulcer to the left heel. A quarterly assessment, dated 1/17/25, showed a staff assessment of Resident #7 was conducted. The staff assessment showed Resident #7 was severely impaired for daily decision making and was totally dependent on staff for care. On 04/02/25 at 2:39 p.m., CNA #2 stated they should have been wearing a gown. On 04/02/25 at 2:44 p.m., RN # 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide supervision to prevent elopement for one (#1) of three sampled residents who were reviewed for elopement. The administrator identified 12 residents who were high risk for elopement. Findings: The undated Wandering and Elopements policy, read in parts, .If a resident is missing initiate the 'Elopement/Missing Resident Emergency Procedure' .Determine if the resident is out on an authorized leave or pass .If the resident was not authorized to leave, initiate a search of the building(s) and premises; and .If the resident is not located notify the administrator and the DON, the resident's legal representative, the attending physician and law enforcement . Resident #1 had diagnoses which included dementia. The Wandering Risk Scale, dated 07/04/24, documented the resident was at risk to wander. The Care Plan, dated 07/22/24, documented the resident was an elopement risk/wanderer related to a history of attempts to leave the facility unattended and wandered aimlessly. A Form 283 Incident Report, dated 08/12/24, documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · E2023-12-14 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to post the accrued interest on three (#12, 23, and #28) of five residents whose funds were deposited in the facility trust. The DON documented 13 residents with funds in the trust. Facility census: 54 Findings: The facility's Deposit of Resident Funds policy, revised 12/2006, documented the deposited funds in excess of fifty dollars would be placed in an interest-bearing account maintained at a bank. 1. The ledger sheet for Resident #12 documented funds in excess of $100 dollars from 07/12/23 through 12/03/23. There was no documentation accrued interest was applied to the account. 2. The ledger sheet for Resident #23 documented funds in excess of $100 dollars from 05/08/23 through 12/14/23. There was no documentation accrued interest was applied to the account. 3. The ledger sheet for Resident #28 documented funds in excess of $100 dollars from 06/27/23 through 12/14/23. There was no documentation accrued interest was applied to the account. On 12/14/23 at 2:13 p.m., the accounts receivable manager stated the ledger sheets…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to maintain an accurate accounting of resident monies for one (#28) of five residents whose funds were managed in the facility trust and failed to ensure the accuracy of vendor payments for two (#34 and #43) of five residents whose funds were managed in the facility trust. The DON documented 13 residents with funds in the trust. Facility census: 54 Findings: 1. The ledger sheet for Resident #28 documented in July 2023, the resident was charged for two vendor payments, leaving a net gain of $252.00 to their account. The ledger sheet documented in August 2023, the resident was charged one vendor payment, leaving a net gain of $411.00 to their account. The ledger sheet documented in September 2023, the resident was charged one vendor payment, leaving a net gain of $411.00 to their account. The ledger sheet documented in October 2023, the resident was charged one vendor payment, leaving a net gain of $365.00. On 12/14/23 at 1:40 p.m., the administrator was shown the ledger sheet for Resident #28. The administrator stated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0570 — patternAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to maintain a bond greater than the balance of the facility managed residents' trust. The DON documented 13 residents with funds in the trust. Facility census: 54 Findings: The facility bond, dated 09/21/08, documented an $8000.00 bond securing the residents' funds in the trust. The facility bond, dated 04/14/16, documented the bond was adjusted from $8,000.00 to $20,000. The facility trust bank statement balance, dated 09/06/23, documented a balance of $51,229.43. The facility trust bank statement balance, dated 10/05/23, documented a balance of $46,080.48. The facility trust bank statement balance, dated 11/08/23, documented a balance of $48,194.53. On 12/14/23 at 2:00 p.m., the accounts receivable manager stated the bond was not high enough to cover the resident trust and would be adjusted.
- Potential for harm · E2023-12-14 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 the correct dose of an ordered medication was administered for one (#9) of seven residents observed for medication administration. The DON stated 53 residents received medications. Facility census: 54 Findings: Resident #9 had diagnoses which included congestive heart failure, chronic kidney disease, atrial fibrillation, cellulitis, and venous stasis ulcers of the bilateral lower extremities. A physician's order, dated 11/10/23, increased the resident's furosemide, a diuretic, from 20mg twice daily to 40mg twice daily. A hospital Discharge summary, dated [DATE], documented the resident was hospitalized from [DATE] to 11/20/23 for pneumonia, cellulitis, and congestive heart failure. A prescription history report, dated 12/14/23, documented the pharmacy delivered 28 tablets of 40mg furosemide on 11/10/23 and again on 12/11/23. There were 31 days between fill dates and 28 tablets was enough medication to administer the twice daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure: a. CMA #1 dispensed an oral medication without touching the medication with their bare hands; b. the registered nurse rinsed a nebulizing mask clean after use; c. LPN #1 cleansed a wound in a manner to prevent contamination of the wound bed; and d. Paid Feeding Assistant #1 fed each spoonful of food to a resident in a manner which minimized the risk of infection. The DON stated 53 residents received medications. The DON documented four residents received nebulizing breathing treatments. The DON documented seven residents received wound care. The administrator stated there was one feeding assistant. Facility census: 54 Findings: 1. On 12/13/23 at 4:20 p.m., CMA #1 was observed to drop a Celebrex tablet onto the medication cart. With their bare hands, CMA #1 picked up the tablet and placed it in the souffle cup with the other medications to administer. CMA #1 was observed to administer the Celebrex to resident #9. On 12/14/23 at 9:15 a.m., CMA #1 stated handling the medication with their bare hands was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-11-30 · tag F0582 — patternGive 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 that the proper SNF ABN or NOMNC for two (#100, and #101) of three sampled residents who where reviewed for SNF beneficiary notices. A Beneficiary Notices form, undated, documented 15 residents had been discharged from skilled services with days remaining in the past six months. Findings: A Transfer or Discharge policy, dated December 2016, read in part, The business office is responsible for, informing the resident, of his or her representative of NOMNC and ABN per Medicare guidelines. 1. Resident #101 admitted to skilled services on 07/01/22 with a diagnosis of stage four pressure ulcer of the sacral region and was discharged from skilled services on 08/13/22 due to therapy goals being met. 2. Resident #100 admitted to skilled services on 08/01/22 with a diagnosis of surgical amputation due to gangrene. They were discharged from skilled services on 10/08/22 due to therapy goals being met. Residents #101 and #102 should have been provided a NOMNC. On 11/30/22 at 2:10 p.m., the Administrator was asked if Residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-11-30 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for three (#1, 17, and #44) of three sampled residents reviewed for bathing and nail care had been provided to two (#1 and #17) of three sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 11/28/22, documented 48 residents resided in the facility, 37 residents required one to two person assistance for bathing, and 11 residents were dependent on staff for bathing. Findings: A Fingernails/Toenails policy, revised February 2018, read in parts, .Nail care includes daily cleaning and regular trimming .Documentation .The date and time that nail care was given . 1. Resident #1 admitted on [DATE] with diagnoses which included DM. An admission Assessment, dated 09/28/22, documented the resident required extensive assistance for bathing and personal hygiene. On 11/27/22 at 1:41 p.m., Resident #1 was asked if they had been receiving baths as often as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-11-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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: a. a treatment was provided as ordered, b. staff washed their hands during wound care treatments, and c. pressure relieving boots were applied as ordered for one (#1) of one sampled resident reviewed for pressure ulcers. Findings: Resident #1 had diagnoses which included pressure ulcers. An admission Summary report, dated 09/21/22 at 3:45 p.m., read in part, .Arrived via ambulance .[11:50 a.m.] .Air mattress on bed .multiple wounds .Wound to coccyx, right heel, two wounds on left heel . Braden Scale assessments, dated 09/21/22, 09/28/22, and 10/12/22, documented Resident #1 was at high risk for pressure ulcers. An admission Resident Assessment, dated 09/28/22, documented Resident #1's cognition was intact, they required limited assistance with bed mobility, had unhealed pressure ulcers, three stage four pressure ulcers that were present on admit, and one unstageable pressure ulcer that was present on admit. A Care Plan, dated 10/16/22, documented Resident #1 required total dependence of two 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.
- Potential for harm · E2022-11-30 · tag F0851 — patternElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, and interview, the facility failed to ensure RN coverage seven days a week, eight hours a day for the following: a. five out of 30 days in April 2022, b. five out of 31 days in May 2022, and c. two out of 30 days in June 2022. The Resident Census and Conditions of Residents report, dated 11/28/22, documented 48 residents resided in the facility. Findings: A PBJ Staffing report, dated April 1st through June 30th, 2022, read in parts, No RN Hours .Infraction Dates .04/09 .04/10 .04/16 .04/23 .04/24 .05/08 .05/12 .05/21 .05/22 .05/31 .06/18 .06/19 . FACILITY On 11/30/22 4:31 p.m., the CEO stated they could not verify RN coverage for the above dates.
- Potential for harm · Ecited before2022-11-30 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure: a. staff were face masks in the facility during a COVID-19 outbreak and the facilities community transmission rate high, and b. staff wore the appropriate PPE while providing care for one (#149) of one sampled resident reviewed for infection control. The Resident Census and Conditions of Residents report, dated 11/28/22, documented 48 residents resided in the facility. The DON identified one resident who was COVID-19 positive and they were in outbreak status. Findings: A Mask policy, dated 11/01/22, read in parts, .If the county transmission level is high .staff and visitors will wear face coverings .If the facility is in Outbreak for COVID-19 .staff and visitiors will wear isolation or sugical masks at all times .N95's or higher masks are to be worn in isolation/quarantine rooms . Resident #149 had diagnoses which included COVID-19. On 11/27/22 at 11:00 a.m., upon entrance to the facility, RN #1, RN #2, CNA #1, CNA #3, CNA #6, CNA #7. On 11/28/22 at 7:41 a.m., RN #1 was observed outside resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-30 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 record review, observation, and interview, the facility failed to ensure kitchen equipment was maintained clean for the deep fat fryer and the stove top. The DON identified 48 residents received services from the kitchen. Findings: A Sanitization policy, dated October 2008, read in parts, .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils .All Equipment shall be kept clean, maintained in good repair .The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and clean after each task before proceeding to the next assignment. On 11/27/22 at 1:30 p.m., during a tour of the kitchen, the following observations were made: a. the deep fat fryer had grimy build up on it, the grease in it appeared dark and in need of being changed out, and b. the stove top had grimy build up and food crumbs on it, On 11/27/22 at 1:35 p.m., the CDM was asked how often the deep fat fryer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-30 · tag F0888 — isolatedEnsure staff are vaccinated for COVID-19
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 staff who were not fully vaccinated, had been granted an exemption or temporary delay from the COVID-19 vaccine for one (#4) of 33 staff members reviewed for COVID-19 vaccination status. The COVID-19 Staff Vaccination Status report, undated, documented the facility had 33 staff members and one staff member was partially vaccinated. Findings: A COVID-19 Vaccination policy, undated, read in part, .staff will be considered fully vaccinated if it has been 2 weeks or more since they completed a primary series for COVID-19 . A COVID-19 Staff Vaccination Status report, undated, documented one staff member, CNA #4, was partially vaccinated. On 11/28/22 at 5:02 p.m., the IP was asked to explain why CNA #4 was partially vaccinated. They stated CNA #4 just hadn't gotten their second dose of the vaccine. The IP was asked when CNA #4 had been hired. They stated on 08/02/22. On 11/29/22 at 10:49 a.m., the IP was asked what the policy was for staff COVID-19 vaccinations. They stated the facility prefers them to be vaccinated. 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$46,898 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $46,898 — penalty dated 2025-04-04
- Medicare payment denial — starting 2025-05-08 for 36 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GRANT RHODES REVOCABLE TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 01/01/2017 |
| JEFFREY W YOUNG REVOCABLE TRUST DATED JULY 27, 2017 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 01/01/2017 |
| RHODES, JONATHAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 01/01/2017 |
| YOUNG, JEFFREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 01/01/2017 |
| SNOW, LARRY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/06/2025 |
| BEDLAM PROPERTIES HO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/06/2025 |
| LIETZKE, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/06/2025 |
| BLACK DIAMOND INVESTMENTS | Organization | ADP OF THE SNF | — | since 12/27/2024 |
| MATRIX PROVIDER SOLUTIONS LLC | Organization | ADP OF THE SNF | — | since 01/06/2025 |
| CARSON, JONATHAN | Individual | ADP OF THE SNF | — | since 12/27/2024 |
| SPILLARS, RODGER | Individual | ADP OF THE SNF | — | since 01/06/2025 |
CMS files one row per role, so the 19 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% 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 $804K paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375402. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-04, 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.