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Rainbow Health Care Community And Rainbow Assisted

111 East Washington, Bristow, OK 74010 · For profit - Limited Liability company · 106 certified beds · (918) 367-2246 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Jan 20241 immediate-jeopardy citation$53,804 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $53,804 in federal fines (most recent 2024-11-12)
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
700 W 7th Ave · (918) 367-8818 · Call to confirm hours
Pharmacy
201 E 7th Ave · (918) 367-3328 · Call to confirm hours
Grocery
210 W 4th Ave · (918) 367-6564 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
201 E Washington Ave · (918) 367-2449

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 5 of 5
Long-stay residentspeople who live here 5 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 improved from 2 to 4 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 rating4★
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 increased5.2%13.6%15.4%better
Long-stay residents who lose too much weight0.0%3.3%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.8%2.0%better
Long-stay residents with depressive symptoms14.3%3.4%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.9%4.7%3.3%better
Long-stay residents whose ability to walk worsened7.7%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication33.8%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.6%95.3%typical
Long-stay residents with pressure ulcers2.7%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control20.1%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table4.6%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine97.7%74.1%79.4%better
Short-stay residents rehospitalized after admission21.8%27.3%22.6%typical
Short-stay residents with an outpatient ER visit12.0%16.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.062.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.432.961.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.5% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.5%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
48.3%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 48.3% 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 29 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.5%CMS range 34.8–65.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 6.0–12.910.7%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 discharge48.3%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 discharge55.2%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 discharge37.9%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 identified100.0%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.2%CMS range 3.7–14.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 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

0.29
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.56
Total nurse hours/ resident / day
0.15
RN hoursweekends
51.9%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 106 beds and averages 79.9 residents a day — about 75% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 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 2.99 hrs/resident/day on weekends vs 3.79 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.35 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

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

2
deficiencies at the latest standard inspection (2025-07-24)
13
at the previous standard inspection (2024-03-01)

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-11-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    On 11/07/24, an IJ situation was determined to exist related to the facilities failure to ensure staff were aware of proper transportation after a resident slid out of a wheelchair during a transport. On 10/29/24, Resident #3 came out of their wheelchair during a transport from the hospital to the facility when the facility driver had to slam on the brakes. CNA #1 and transport driver #1 where unable to lift Resident #3 back into the wheelchair. This resulted in Resident #3 riding approximately 30 miles on the floor of the transport van. On 11/07/24 at 1:20 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 11/07/24 at 1:30 p.m., the administrator was notified of the IJ situation and the IJ template was provided. On 11/08/24 at 10:29 a.m., an acceptable plan of removal was provided. The plan of removal documented: There is the potential for serious harm, impairment, or death if the transportation vehicle is involved in an accident. Current driver training acknowledgment will be updated to include 'van will not operate unless…

    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 before2026-06-17 · 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 — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure food was not served beyond their expiration date. The administrator identified 84 residents received nourishment from the kitchen. Findings: On 06/15/26 at 12:38 p.m., the following observations were made during the tour of the kitchen:a. in the refrigerator, an opened one-gallon container of tartar sauce was observed to be dated 01/20/26, handwritten on the lid. The container had a manufacture date of 12/06/25, and b. in the walk-in cold storage, an unopened half-gallon container of buttermilk was observed with a best-by of 06/01/26. An unopened gallon container of whole milk was observed with a best-by date of 06/11/26. A policy titled Refrigeration, revised 08/21/24, read in part, Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety. On 06/15/26 at 12:52 p.m., the dietary manager stated the tartar sauce should have been disposed of long ago. The dietary manager stated expired milk products were to be…

    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 · D2025-07-24 · tag F0577 — isolated
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 most recent survey results of the facility were posted in a place readily accessible to residents, family members and legal representatives of residents.The DON reported 75 residents resided at the facility.Findings:On 07/23/25 at 10:52 a.m., the survey results binder was observed to be sitting on the ledge of a half wall between the receptionist's desk and the common room used for activities. A small end table, a soda machine, and a large circular dinner table were blocking access to the binder on one side, and the other side was only accessible from behind the receptionist's desk. On 07/23/25 at 10:46 a.m., all four residents that attended the resident council meeting stated they did not know anything about the survey results binder, nor did they know where to find it, but they would be interested in reading the results. On 07/23/25 at 10:54 a.m., the administrator stated someone had not moved the table back to its correct position after the residents completed their exercise activity at 10 a.m. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-24 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 controlled medication was secured in a locked container that was permanently affixed to the building for 1 (#14) of 1 sampled resident reviewed for medication storage.The DON reported 75 residents at the facility were administered medications at the facility.Findings:On 07/23/25 at 1:00 p.m., CMA #3 was observed entering the facility medication storage room while the surveyor was conducting their inspection inside the room. CMA #3 was observed opening a refrigerator unit. A small black lock box approximately 7 inches square and 2 inches deep was observed inside the unit. The refrigerator door did not have a lock on it.On 07/24/25 at 12:00 p.m., CMA #1 was observed to enter the facility medication storage room, opened the refrigerator which contained the small black lockbox. The CMA was observed to be able to remove the lockbox from the refrigerator as the lockbox was not secured to the refrigerator by any means.A facility policy titled Medication Storage in the Facility, dated 2024, read in part,…

    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 before2024-11-12 · 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 proper handwashing was conducted during incontinent care, between residents, and/or a roll gauze that was dropped on the floor was not used to perform a treatment for seven (#1, 2, 5, 6, 7, 8, and #9) of seven sampled residents observed for infection control. The charge nurse identified 70 residents resided in the facility. Findings: A Hand Hygiene policy, dated 04/28/22, documented hand hygiene should be performed before and after providing care, before and after applying and removing gloves, and after handling soiled linens. It documented staff could use alcohol based hand rub if their hands were not visibly soiled. An Incontinent Care policy, dated 07/21/22, read in part, Perform Hand Hygiene and Apply Gloves .Remove Soiled Brief .Cleanse Perineal Area .Remove Soiled Gloves, Perform Hand Hygiene & Apply Clean Gloves .Apply Clean Brief & Clothing .Discard Contaminated Items .Remove Gloves & Perform Hand Hygiene On 11/05/24 at 10:11 p.m., CNA #2 was observed touching Resident #5's incontinent brief…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-01 · 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 and interview, the facility failed to ensure a sanitary environment in the shower rooms. The DON identified 76 residents who reside at the facility. Findings: A Quality of Life-Homelike Environment policy, dated 02/01/16, read in part, .2. The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .a. Cleanliness and order . A Resident Council Meeting form, dated 02/13/24 documented the residents stated that the shower rooms were not cleaned up after the previous shower. On 02/26/24 at 10:52 a.m., the shower room located on Park Place Hall was observed to have hard water/lime/calcium deposits on the faucet. There was also a thick black substance in the corners of the shower stall and between the floor tile grout lines. The silicone caulking was coming loose from the corners of the shower stall walls and between the floor tiles and had a thick black substance underneath it. On 02/27/24 at 8:16 a.m., the shower room located on Hummingbird…

    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 · E2024-03-01 · 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

    Based on record review and interview, the facility failed to ensure ongoing assessment including pre/post assessments were completed for two (#129 and #25) of two residents who were reviewed for dialysis. The DON identified four residents who received dialysis services. Findings: The Dialysis Communication policy, dated 09/27/23, read in part, .The top section of the Dialysis Communication Transfer From is completed by the Nurse responsible for sending the resident to the Dialysis Unit/Facility .The bottom section of the form is completed by personnel responsible for the resident at the Dialysis Facility and returned to the nursing home with the Resident .Once the form is completed, the most recent form should be stored in the medical record . 1. Resident #129 had diagnoses which included dependence on renal dialysis. The Baseline Care Plan, dated 02/21/24, documented the resident required dialysis. The Long Term Care Evaluation, dated 02/21/24, documented the resident was scheduled for dialysis Monday, Wednesday, and Friday and the location of the dialysis access was the left…

    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 · E2024-03-01 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to offer the residents an HS snack and ensure snacks were served to the residents in accordance with the facility policy, for three (#11, 16, and #25) of three sampled residents reviewed for food and nutrition services. The DON identified 76 residents resided in the facility. Findings: A facility policy titled, Meals & Snacks, dated 11/27/23, documented, .3. An evening snack shall be provided by Nutritional Services and offered to the residents by Nursing . On 2/26/24 at 11:43 a.m., the dietary manager was asked about the resident snack schedule. They stated dietary prepares snacks for the residents at 10 a.m., 2 p.m., and a bedtime snack around 7 p.m. They stated the snacks are placed at the nurse station. 1. Res #11 had diagnoses which included diabetes, protein-calorie malnutrition, and muscle wasting. On 02/25/24 11:52 a.m., Res #11 was asked if they were being offered a snack at bedtime. They stated they have never been offered a snack at bedtime. On 02/27/24 10:36 a.m., Res #11 was asked if they were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-01 · 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 — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure the ice machine was clean. The DON identified # residents ate from the kitchen. Findings: A Nutritional Services Sanitation policy, reviewed 11/27/23, read in parts, .Nutritional Services shall ensure a clean and sanitary work environment; to promote to promote and protect food safety; and, to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety .Cleaning of equipment .ice machines, etc shall be completed by the maintenance department .Equipment shall be cleaned, sanitized, delimed .in accordance with manufacturer recommendations . On 02/25/24 at 11:22 a.m., the ice machine was observed to have black and pink substances on the deflector plate in the bin of the ice machine. Ice was observed to be touching the deflector plate. On 02/25/24 at 11:23 a.m., [NAME] #1 stated they did not know what the substance was but it was disgusting. They stated it should not be served. On 02/25/24 at 1:30 p.m., the dietary supervisor stated the ice should not be used and the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-01 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure staff followed infection control protocols while delivering meals to residents in the dining room. The administrator identified 76 residents who resided in the facility. Findings: On 02/25/24 at 12:41 p.m., the noon meal was observed in the dining room. DA #1 was observed to not sanitize their hands between plates. DA #1 was observed to touch their pants and facial hair net between delivering resident plates. DA #2 was observed to not sanitize their hands between resident plates while touching the rim of a cup of cobbler and touching their pants. On 02/25/24 at 12:49 p.m., DA #2 was observed to sanitize their hands, but continued to touch their pants. On 02/26/24 at 9:08 a.m., the Dietary Supervisor stated they expected staff to use hand sanitizer only if they cannot get to the sink and between plates.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-01 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents were offered the opportunity to formulate an advance directive for one (#31) of three sampled residents who were reviewed for advance directives. The DON identified 76 residents who resided in the facility. Findings: The Advanced Directives policy, dated 04/26/23, read in part, .Upon admission the Facility will provide Resident who is Medically Deemed Competent or Resident Representative, who does not have an existing Advance Directive, with written information and instructions regarding the Right to make Advance Directives prior to the initiation of Care or at any requested time . Resident #31 had diagnoses which included unspecified dementia. The face sheet for Resident #31 documented the resident was a full code. Review of the electronic clinical record did not reveal the resident had been offered the option to formulate an advance directive. On 02/27/24 at 3:10 p.m., the social services director stated they would review the clinical record for documentation related to the advance directive. On 02/27/24…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2024-03-01 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure care plans were reviewed and revised for two (#16 and #43) of nine residents who were reviewed for care plans. The DON identified 76 residents who reside at the facility. Findings: The Care Plan for Resident #43, initiated 11/03/23, documented a fall risk focus for mobility. The care plan documented the resident was a fall risk due to weakness affecting the left dominant side. Last revised 02/28/24. The care plan documented Resident #43 would not sustain serious injury through the review date, and to notify the physician of fall with recent medication changes. The care plan documented to ensure proper body alignment/position while in bed, ensure the call light was within reach and encourage use for assistance as needed. There was no mention of a fall mat placed next to the bed of Resident #43. 1. Resident #43 admitted with diagnoses which included hemiplegia, hemiparesis, and muscle weakness. The Care Plan for Resident #43,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure fall mats were properly placed for two (#43 and #10) of two resident who were reviewed for accident hazards. The DON identified # residents who were at risk for falls. Findings: An Accident & Incident Documentation & Investigation policy, revised 04/26/23, read in parts, .The Licensed Nurse shall document the Incident and notify the supervisor and Director of Nursing for follow through as needed .The licensed Nurse may complete a Nurses' Note and update the Resident Care Plan as needed . 1. Resident #43 admitted with diagnoses which included hemiplegia, hemiparesis, and muscle weakness. A Fall Incident report, dated 02/20/24, read in parts, Resident #43, .laying on floor parallel to bed on her back .rolled out of bed, change in condition compared to before hospitalization, bed in low position, fall mat in place . A Fall Incident report, dated 02/21/23, read in parts, [Resident #43 was in the floor .I slid off the bed and hit my head and back .fall matt placed by bed . A fall risk evaluation completed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 nutritional supplements were provided as ordered for one (#73) of seven residents who were reviewed for nutrition. The DON identified 19 residents who were ordered nutritional supplements. Findings: The Nutritional Supplements policy, dated 12/01/22, read in part, .The Facility will have a formulary of Nutritional Supplements to be utilized as interventions to help ensure nutritional needs are met. Supplements may be available through the Nutritional Services or Nursing Department . Resident #73 had diagnoses which included chronic obstructive pulmonary disease. An admission assessment, dated 01/05/24, documented the resident was cognitively intact for daily decision making. A physician order, dated 02/15/24, documented the resident was ordered a house shake twice daily for weight support. On 02/25/24 at 11:43 a.m., the resident stated they had not been receiving a nutritional supplement. The Care Plan, updated 02/27/24, documented the resident had weight loss related to diuretic use and had house shakes 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-01 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 two (#11 and #16) of two sampled resident reviewed for side rails. The ADON identified four residents had grab bars/u-rails attached to their beds. Findings: 1. Res #11 had diagnoses which included diabetes, unsteadiness of feet, lack of coordination, anxiety, osteoporosis cerebral infarct, HTN, and CHF. A quarterly assessment, dated 01/17/24, documented the resident's cognition was intact, required substantial assistance with most ADLs, had impairment on one side of their upper and lower extremities, and was always incontinent of bowel and bladder. On 02/25/24 at 10:21 a.m., the resident was observed in their bed with one-quarter rail to the upper right side of the bed. The quarter rail was pulled up. The resident…

    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 before2024-03-01 · tag F0757 — failed to avoid unnecessary drugs — isolated
    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 side effect monitoring was implemented for anticoagulant medications for two (#3 and #129) of six sampled residents whose medications were reviewed. The DON identified 12 residents who were ordered anticoagulant medications. Findings: 1. Resident #3 had diagnoses which included atrial fibrillation. The care plan, dated 10/10/23, documented the resident received Coumadin and had an increased risk of bleeding. The care plan documented to monitor for side effects. The MAR/TAR, dated December 2023, documented the resident received Coumadin (an anticoagulant/blood thinner) 2mg once daily. The MAR and TAR did not document side effect monitoring for the Coumadin. The MAR/TAR, dated January 2024, documented the resident received Coumadin 2mg once daily. The MAR and TAR did not document side effect monitoring for the Coumadin. The quarterly assessment, dated 01/17/24, documented the resident had received an anticoagulant medication during the look back period. The MAR/TAR, dated 02/01/24 through 02/27/24, documented 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-01 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure the medication error rate was below five percent. A total of 28 opportunities were observed with two medication errors. Total medication error rate was 7.14%. The DON identified 76 residents resided in the facility. Findings: 1. Res #3 had diagnoses which included cellulitis, low protein, and low albumin levels. A physician order, dated 10/10/23, documented to administer Arginaid two times daily for wound support and low protein and albumin. On 02/26/24 at 7:32 a.m., CMA #2 was observed during medication pass and did not administer the Arginaid. The CMA was asked why they did not administer it. They stated because Res #3 always refuses it. They were asked if they offered the Arginaid to Res #3. They stated they did not and that the Arginaid needed to be discontinued from the MAR. The February 2024 MAR, documented the Res #3 had not taken the Arginaid 51 times for the month. 2. Res #40 had diagnoses which included constipation. A physician order, dated 03/13/23, documented to administer Miralax oral…

    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 · D2024-03-01 · tag F0848 — isolated
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    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 arbitration agreements provided for the selection of a neutral arbitrator and a neutral venue agreed upon by both parties for one (#129) of two sampled residents who were reviewed for arbitration agreements. The administrator identified 76 residents who resided in the facility. Findings: A copy of the Agreement to Arbitration, provided by the administrator, read in part, .The Agreement .The parties choose to settle any future claims or controversies through binding arbitration administered by the American Health Lawyers Association (AHLA) .the arbitration will be at the Facility and conducted in accordance with the AHLA Rules . Resident #129 was admitted to the facility on [DATE]. Review of the clinical record revealed an Agreement to Arbitration, had been signed by the resident's representative on 02/22/24. The signature page of the agreement had been scanned into the electronic clinical record. On 02/27/24 at 11:27 a.m., the administrator 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-17 · tag F0604 — failed to not use physical restraints improperly — pattern
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 residents were free from physical restraints which were not required to treat the resident's medical symptoms for one (#1) of two residents reviewed for restraints. The administrator identified 78 residents resided in the facility. Findings: A facility policy titled Physical Restraint , dated 07/26/23, read in part, .Policy: Physical Restraints are not to be used to limit Resident mobility for the convenience of staff .Procedure . Prior to using a Restraint, an evaluation of the Resident should be completed .A Physician's Order for a Restraint includes the type of least restrictive Restraint .The Restraint-Physical Restraint UDA and Restraint Consent UDA is completed prior to implementing a Restraint .The IDT Team evaluates continued need and use of the Restraint quarterly and as needed . Res #1 had diagnoses which included difficulty in walking, other abnormalities in gait and mobility, lack of coordination, mild intellectual disability, and arthropathy. An incident report, dated 03/03/23 at 3:24…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-26 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 medication administration error rate was less than five percent for two (#13 and #70) of five sampled residents observed during the medication pass. There were four medication errors out of 27 opportunities, which made the error percentage rate 14.81 percent. The Resident Census and Conditions of Residents form documented 76 residents resided in the facility. Findings: Review of the facility policy titled, Medication Administration and General Guidelines read in part .Medications are administered as prescribed, and in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so .Medications are administered within one hour of the scheduled time .Adheres to the 6 rights of Medication Administration .Right Time . 1. Resident #13 had diagnoses which included dependence on renal dialysis and chronic obstructive pulmonary disease. Review of Physician orders, dated active as of 01/24/23, documented atorvastatin calcium tab 10 Milligram (MG)…

    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 before2023-01-26 · 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 — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure: a. the kitchen was maintained clean and in good repair, and; b. staff did not handle foods with their bare hands. The dietary manager identified 75 residents received services from the kitchen. One resident received nutrition and hydration solely through a feeding tube. Findings: On 01/23/23 at 10:45 a.m., an initial tour of the kitchen was conducted. The following observations were made: a. there was no hot water at the hand sink in the employee restroom. The water temperature was 52 degrees Fahrenheit, and; b. there was black residue on the deflector shield inside of the ice machine. On 01/24/23 at 11:03 a.m., a follow-up tour of the kitchen was conducted. The following observations were made: a. there was no hot water at the hand sink in the employee restroom. The water temperature was 52 degrees Fahrenheit, and; b. the dietary supervisor in training was standing at the stove preparing food for the lunch meal. They touched raw breaded shrimp in a white box with their left bare hand. They did not use a glove or any…

    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 · D2023-01-26 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to post nurse staffing information daily, which included all of the required components. The Resident Census and Conditions of Residents form documented 76 residents resided in the facility. Findings: On 01/23/23 at 12:30 p.m., an observation was made of the nurse staffing information posted by the nurse's station. It was dated 01/22/23, did not include the name of the facility, and had not been updated for 01/23/23. On 01/24/23 at 10:30 a.m., the nurse staffing posted was observed to be dated 01/22/23. On 01/25/23 at 11:15 a.m., the nurse staffing posted was observed to be dated 01/22/23. On 01/26/23 at 8:30 a.m., the nurse staffing posted was observed to be dated 01/22/23. On 01/26/23 at 9:30 a.m., the administrator reported, It should have been changed each day and I will add the required information that is missing.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    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, it was determined the facility failed to ensure residents were free of duplicate medication dosage for one (#16) of five residents reviewed for unnecessary medication. The Resident Census and Conditions of Residents, dated 01/23/23, documented 76 residents resided in the facility. Findings: The facility's Medication Administration policy, dated 2019, read in parts, .Medications are administered in accordance with written orders of the attending physician .All current medications and dosage schedules are listed on the resident's MAR . Resident #16 had diagnoses which included congestive heart failure and hypertension. The quarterly MDS Assessment, dated 10/19/22, documented the resident was cognitively intact. The resident's Drug Regimen Review, conducted by the consulting pharmacist on 10/30/22, read in parts, .08/27/22 Potassium 20 meq bid .10/29/22 Potassium 20 meq bid .Please review and advise if both orders are required . The resident's MAR, dated November 2022 and December 2022, read in parts, Potassium Chloride ER tablet extended release…

    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

“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

$53,804 in federal fines across 1 penalty.

  • $53,804 — penalty dated 2024-11-12

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to MGM HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.3+1.7 vs chain
Health inspection 3 of 52.4+0.6 vs chain
Staffing 3 of 51.7+1.3 vs chain
Quality measures 5 of 53.6+1.4 vs chain
The other 26 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Arbor Hills Care & Rehab CenterFerguson, MO 1 of 5Bentwood Nursing & RehabFlorissant, MO 1 of 5Broadway Care & Rehab CenterMuskogee, OK 1 of 5Florissant Valley Health & Rehabilitation CenterFlorissant, MO 1 of 5Lansdowne VillageSaint Louis, MO 1 of 5Leisure Village Health Care CenterTulsa, OK 1 of 5Normandy Nursing CenterSaint Louis, MO 1 of 5Quarters At Des Peres, TheDes Peres, MO 1 of 5South Pointe Rehabilitation and Care CenterOklahoma City, OK 1 of 5Springfield Skilled Care CenterSpringfield, MO 1 of 5St Sophia Health & Rehabilitation CenterFlorissant, MO 2 of 5Eastgate Village Care & Rehab CenterMuskogee, OK 2 of 5Heritage Villa Care & Rehab CenterBartlesville, OK 2 of 5Sherbrooke VillageSaint Louis, MO 2 of 5Spring Valley Health & Rehabilitation CenterSpringfield, MO 2 of 5Sunset Health Care CenterUnion, MO 2 of 5Walnut Grove Care & Rehab CenterMcAlester, OK 3 of 5Forest Hills Care And Rehabilitation CenterBroken Arrow, OK 3 of 5Fort Gibson Care & Rehab CenterFort Gibson, OK 3 of 5Oak Park Care CenterSaint Louis, MO 4 of 5Cleveland Care And Rehab CenterCleveland, OK 4 of 5Coweta Care & Rehab CenterCoweta, OK 4 of 5Jackson ManorJackson, MO 4 of 5Mitchell Care & Rehab CenterMcAlester, OK 4 of 5Seminole Care And Rehabilitation CenterSeminole, OK 5 of 5Camelot Nursing And Rehabilitation CenterFarmington, MO

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
MLS ACQUISITION LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 07/01/2019
JEREMIAS, BARUCHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/01/2019
KEIFER, JERRYIndividualW-2 MANAGING EMPLOYEEsince 03/29/2021
BIENSTOCK, JUDAHIndividualCORPORATE OFFICERsince 01/01/2015

1 organizational owner 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.

$7.1M
Net patient revenuemost recent cost report
+8.3%
Operating marginrevenue minus expenses
$738K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 10%Other / private 8%

About 81% 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 $738K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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

$237per resident / day
operating cost
$7,204per month
≈ monthly operating cost
$258per 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 375320. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-24, 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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