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Broken Arrow Nursing Home, INC

424 North Date Avenue, Broken Arrow, OK 74012 · For profit - Corporation · 101 certified beds · (918) 251-5343 Medicare & Medicaid certified

Call the home — (918) 251-5343 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0603) — most recent Nov 2024Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0603) — most recent Nov 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (58%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
118 W Commercial St · (918) 893-3520 · Call to confirm hours
Pharmacy
1030 E Lansing St · (918) 251-3784 · Call to confirm hours
Grocery
805 N Sycamore Ave · (918) 994-6086 · Call to confirm hours
Park
7101 S 3RD St · (918) 615-6099 · Typically dawn to dusk
Place of worship
520 W Broadway Ave · (888) 887-9673

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 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 increased18.1%13.6%15.4%worse
Long-stay residents who lose too much weight4.0%3.3%5.4%better
Long-stay residents with a catheter left in their bladder1.9%1.9%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.6%2.8%2.0%worse
Long-stay residents with depressive symptoms3.3%3.4%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury8.2%4.7%3.3%worse
Long-stay residents whose ability to walk worsened21.7%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication23.2%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine95.9%94.6%95.3%typical
Long-stay residents with pressure ulcers3.2%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control19.8%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table5.2%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 vaccine36.0%74.1%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.922.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.492.961.80better

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

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

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

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

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

0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 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

0.14
RN hours/ resident / day
0.95
LPN hours/ resident / day
2.84
Aide hours/ resident / day
3.93
Total nurse hours/ resident / day
0.14
RN hoursweekends
58.3%
Total nursing turnover
100.0%
RN turnover

How full it usually is: this home is certified for 101 beds and averages 66.6 residents a day — about 66% occupied, or roughly 34 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.14 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.84 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 3.32 hrs/resident/day on weekends vs 4.17 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.13 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above 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

1
deficiencies at the latest standard inspection (2024-11-01)
6
at the previous standard inspection (2023-09-28)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2025-08-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an environment free of accident hazards for 1 (West hall) of 5 resident halls. The director of nursing identified five residents wandered the [NAME] hall. Findings:On 08/14/25 at 12:10 p.m., the beauty shop door was open on the [NAME] hall. The beauty shop was unattended and a jar with a silver lid laid askew read, Barbicide Disinfectant Fungicide & Virucide. The jar was approximately half full of a dark colored fluid. There was an unsecured wood and glass cabinet with a shelf of hair care products which included Equate Brand Firm Hold hair spray, Sexy Hair Big Spray and Play Harder firm volumizing hairspray, Pravana Super Shape Extreme hair spray, and Biolage Hydra Source Detangling Solution. The door to the beauty shop was observed to have no lock to secure the door/room.On 08/14/25 at 12:12 p.m., the [NAME] hall was observed. There was a coaxial cord wrapped around the handrail and looped over the door handle of resident room…

    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 · D2024-11-01 · tag F0603 — failed to not confine residents against their will — isolated
    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview , the facility failed to ensure a resident had the right to be free from involuntary seclusion for one (#33) of one sampled resident reviewed for involuntary seclusion. The administrator identified 66 residents in the facility. Findings: A polity titled Abuse, Neglect, Exploitation, dated 10/01/17, documented the facility staff would not use involuntary seclusion. Resident #33 had diagnoses which included congestive heart failure. The resident resided in a room with their spouse. A progress note, dated 10/24/24 at 7:07 a.m., documented the resident was sent to a local hospital. A progress note, dated 10/28/24 at 5:23 p.m., documented the resident returned from the hospital, inquired about their spouse, and was told the spouse was aware of the resident's return to the facility. A progress note, dated 10/29/24 at 7:05 p.m., documented the resident remained on quarantine protocol per readmission. On 10/30/24 at 9:02 a.m. Resident #33 was observed in a room alone. On 10/31/24 at 09:36 a.m., the administrator stated all new residents and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-08 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure the call light was in reach for one (#1) of three residents reviewed for accommodation of needs. The administrator reported the census was 61. Findings: Resident #1 had diagnoses which included chronic kidney disease and edema. A significant change assessment, dated 10/30/23, documented Resident #1 cognitively intact for daily decision making and dependent on staff assistance for transfers. A care plan intervention, dated 04/07/23, documented Strive to keep call light in reach and answer promptly when activated. On 02/05/24 at 10:13 a.m., Resident #1 was observed sitting in a Geri chair in their room, the call light was not in reach. The resident stated staff usually did not leave the call light in reach. On 02/07/24 at 9:05 a.m., the resident was observed in bed, the call light was not in reach. On 02/07/24 at 10:20 a.m., the resident was observed in bed, the call light was not in reach. On 02/07/24 at 1:00 p.m., Resident #1 was observed in bed, the call light was not in reach. On 02/08/24 at 9:00…

    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 · Dcited before2024-02-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure that residents receiving antipsychotic medications were monitored for side effects for one (#2) of three residents reviewed for unnecessary medications. The administrator reported the census was 61. Findings: Resdident #2 had diagnoses which included visual hallucinations and unspecified psychosis. A physician order, dated 01/26/24, documented the resident was to receive risperidone (an antipsychotic) 1 mg by mouth twice a day. A review of Resident #2's medical records did not document the resident was being monitored for side effects of antipsychotic medications. On 02/08/24 at 10:55a.m., the DON reported they did not have documentation of side effect monitoring for Resident #2.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-28 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to provide a SNF ABN to two (#14 and #169) of three sampled residents whose beneficiary notices were reviewed. The MDS Coordinator identified six residents who were discharged from skilled services with Medicare benefit days remaining. Findings: 1. Res #14 was admitted to skilled services on 04/17/23 and discharged from skilled services on 06/08/23 and remained in the facility. A SNF Beneficiary Protection Notification Review documented an ABN was not provided to the resident. 2. Res #169 was admitted to skilled services on 05/22/23 and discharged from skilled services on 07/06/23 and remained in the facility. A SNF Beneficiary Protection Notification Review documented an ABN was not provided to the resident. On 09/27/23 at 2:25 p.m., the MDS coordinator reported Res #12, 14 and #169 were not provided with an ABN because they were not sure when an ABN should be given to a skilled resident.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-28 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to: a. attempt appropriate alternatives prior to installing bed or side rails; b. perform an entrapment risk assessment; c. review the risks and benefits with the resident and/or their representative; d. obtain an informed consent; and e. develop a care plan for side rail use for one (#20) of three residents reviewed for accident hazards. The DON identified 13 residents whose beds were equipped with a bed rail of any type. Findings: A Use of Bedrails policy, revised 11/01/22, read in parts, .If side rails are used in this facility, there must first be an interdisciplinary assessment of the resident, consultation with the attending physician and input from the resident and/or legal representative .Consent shall be obtained from the resident's legal representative prior to the use of bed rails .After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised…

    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 · E2023-09-28 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to complete annual skills competencies for two (CNA #1 and #2) of two CNA's whose employee files were reviewed for skills competencies. There were eight CNA's documented on the staff roster who had been employed over a one year. Findings: CNA #1 was hired on 01/22/21. There was no annual skills competency in CNA #1's employee file. CNA #2 was hired on 03/26/22. There was no annual skills competency in CNA #2's employee file. On 09/27/23 at 9:45 a.m., LPN #1 reported there were no annual skills competencies for CNA #1 and #2. LPN #1 reported they had let annual skills competencies fall by the wayside and needed to start doing competencies again.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-28 · 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 record review and interview, the facility failed to implement a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. The Resident Census and Conditions of Residents documented 63 residents resided in the facility. Findings: The CMS memo 17-30, revised date 06/09/17, documented CMS expects long-term care facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility water systems. On 09/25/23 at 1:00 p.m., the administrator was asked to provide documentation of water management policies and procedures. No documentation of water management policies and procedures were provided. On 09/27/23 at 2:00 p.m., the DON stated the facility had no policy or procedure in place for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. The DON stated having not been aware of the requirement.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-28 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#20) of three residents reviewed for accident hazards. The DON identified 13 residents whose beds were equipped with a bed rail of any type. Findings: Res #20's admission assessment, dated 09/04/23, documented the resident was moderately cognitively impaired and required extensive two-person assistance with bed mobility and transfer. On 09/26/23 at 7:51 a.m., the resident was observed lying supine in bed with half side rails in the up position on both sides of the head of bed. An attempted interview with the resident was unsuccessful due to the resident's cognition. On 09/27/23 at 8:56 a.m., LPN #1 was asked to provide documentation of regular bed rail inspections for the resident. On 09/27/23 at 9:57 a.m., the resident was observed lying supine in bed with half side rails in the up position on both sides of the head of bed. An attempted interview…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · 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 document a resident's code status correctly for one (#38) of 14 sampled residents. The Resident Census and Conditions of Residents form documented 63 residents resided in the facility. Findings: Res #38 was admitted to the facility with diagnoses of dementia, HTN, major depressive disorder, and chronic kidney disease stage IV. On 09/28/23 at 9:35 a.m., a review of the resident's clinical record documented the resident's code status as Do Not Resuscitate (DNR). No documented DNR was located in the resident's EHR or paper chart. The resident had an Advanced Directive for Healthcare which documented the resident did not want life extended by life-sustaining treatment, including artificially administered nutrition and hydration. On 09/28/23 at 9:45 a.m., the DON was asked to look at the resident's code status. She reported it stated the resident's status was DNR. The DON was made aware of the only documentation located in the resident's EHR and paper chart was an Advanced Directive for Healthcare. The DON was asked if the code…

    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 15 citations
  • Potential for harm · E2021-05-19 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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, interview, and record review, it was determined the facility failed to maintain confidentiality of protected health information for one (#29) of 24 residents who were reviewed for privacy. The facility census was 66 residents. Findings: An undated policy titled, Broken Arrow Nursing Home HIPAA Privacy Policy (Health Infurance Portability and Accountability Act of 1996), documented, .We .are required by applicable Federal and State laws to maintain the privacy of your medical information .All of the following are examples of Protected Health Information: demographic information .medication information that relates to you past, present, or future physical or mental health that is collected, created, or received from you, a health care provider, a health plan . Resident #29 was admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease with heart failure and an anxiety disorder. On 05/11/21 at 11:05 A.M., two documents titled, Pertinent admission Evaluation For…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-05-19 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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, interview, and record review, it was determined the facility failed to prevent abuse for two (#11 and #168) of four residents reviewed for abuse. The census and condition report documented 66 residents lived in the facility. Findings: 1. Resident #168 was admitted to the facility on admitted on [DATE] with diagnoses which included dementia without behaviors, depression, and anxiety. The admission assessment, dated 07/28/20, documented the resident was severely impaired for daily decision-making, had no behaviors, required supervision for transfers, and extensive assistance for dressing and bathing. The assessment documented the resident was not steady, could stabilize without help, and ambulated with a walker. Physician orders for September 2020 documented the resident received Ativan for anxiety; Lexapro, Sertaline, and Trazadone for major depression; and Restoril for sleep. A witness statement, dated 09/14/20, documented certified medication aide (CMA) #2 went outside to smoke at 12:15…

    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 · E2021-05-19 · 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, interview, and record review, it was determined the facility failed to provide an environment free from physical restraints for one (#44) of one sampled residents reviewed for restraints. The facility census and condition report identified 34 cognitively impaired residents who lived in the facility. Findings: Resident #44 was admitted to the facility with diagnoses which included Reyes' syndrome, major depressive disorder, pseudobulbar affect, and had a feeding tube. An annual assessment, dated 06/21/20, documented the resident was severely impaired for daily decision-making, did not exhibit behaviors, required extensive to total assistance of one person for transfers, did not ambulate, had impairment for range of motion on upper and lower extremities, required total assistance with a wheelchair for mobility, and was incontinent of bowel and bladder. A care plan, dated 04/13/21, documented the resident was at risk for falls. The care plan documented the resident had diminished cognition, was impulsive, and had poor safety awareness. The care plan 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-05-19 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined the facility failed to implement their abuse policy for two (#11 and #168) for four residents reviewed for abuse. The facility failed to: a) Prevent abuse for residents #168 and #11. b) Protect the resident from continued abuse for resident #168. c) To notify the administrator on call immediately regarding an incident of abuse for resident #168. d) Report an allegation of abuse to the state agency within two hours for resident #168 and #11. e) Screen complete background checks and reference checks for new employees. f) Provide abuse training to new employees hired. The census and conditions report documented 66 residents lived in the facility. Findings: 1. Resident #168 was admitted to the facility on [DATE] with diagnoses which included dementia without behaviors, major depression, and anxiety. The admission assessment, dated 07/28/20, documented the resident was severely impaired for daily decision-making, had no behaviors, required…

    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 · E2021-05-19 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to report allegations of abuse to the administrator and the state agency with in two hours for two (#168 and #11) of four residents reviewed for abuse. The census and conditions report documented 66 residents lived in the facility. Findings: 1. Resident #168 was admitted to the facility on admitted on [DATE] with diagnoses which included dementia without behaviors. The admission assessment, dated 07/28/20, documented the resident was severely impaired for daily decision-making, had no behaviors, required supervision for transfers and extensive assistance for dressing and bathing. The assessment documented the resident was not steady, could stabilize without help, and ambulated with a walker. A witness statement, dated 09/14/20 at 12:45 a.m., documented certified nurse aide (CNA) #3 witnessed LPN #2 being verbally abusive to resident #168 after the resident fell. The CNA stated she heard a bang and went to the 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-05-19 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined the facility failed to: a. ensure a resident's representative participated in the care plan process for one (#28) of 24 residents whose care plans were reviewed, and b. ensure a resident's care plan was updated to include the monitoring of oral intake for one (#32) of 24 residents whose care plans were reviewed. The facility census and condition documented 66 residents resided in the facility. 1. Resident #28 was admitted with diagnoses which included unspecified dementia without behavioral disturbance and cachexia. On 05/11/21 at 11:42 a.m., the resident's representative was asked if she participated in the care plan process. She stated she was not made aware of any care plan meetings. On 05/17/21 at 9:00 A.M., the resident's clinical record was reviewed. The record documented the care plan was updated on: ~ 09/04/20 for a new diagnosis and order. ~ 09/22/20 for a new provider order. ~ 11/19/20 for a quarterly review and update. ~ 11/25/20 for a new provider order. ~ 12/18/20 updated and reviewed for a significant change in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-05-19 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined the facility failed to provide activities for two (#44 and #52), of four residents sampled for activities. The resident census and conditions report identified 66 residents who resided in the facility. Findings: Resident #44 was admitted with diagnoses of Reyes' syndrome. An annual assessment, dated 06/21/20, documented the resident as severely cognitively impaired, no behaviors, extensive to total assistance of one person for transfers, did not ambulate, impairment on both side of upper and lower extremities, used a wheelchair for mobility with total assistance, incontinent of both bowel and bladder. The assessment documented it was important for the resident to have a family involved in discussion about her care, have books to look at, have music to listen to, and go outside when the weather was good. A care plan, dated 4/13/21, documented staff were to provide one to one activities, pet therapy, read her stories, touch the resident often and give her lots of hugs, take the resident outside, take her to live…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-05-19 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to: a. monitor the oral intake for one (#32) of one resident whose diet was upgraded from nothing by mouth to food and fluids by mouth, and b. develop a plan for coordination of care for one (#167) of one resident who received hospice services. The facility identified two residents who received tube feedings and 17 residents received hospice services. Findings: 1. Resident #32 was admitted to the facility with diagnoses which included diabetes, lymphoma, and use of a gastrostomy tube. The physician order, dated 03/11/21, documented the resident was not to take anything by mouth. The care plan, dated 03/11/21, documented the resident received his nutrition and medications via his gastrostomy tube. The dietician's note, dated 04/27/21, documented the resident's weight was stable and the resident was not to receive anything by mouth. The resident was to receive 237 milliliters (ml) of Isosource 1.5 five times a day by gastrostomy tube to provide 1800 kcal (kilocalories), 77 grams of protein, and 895 ml of fluid…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-05-19 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 interview and record review, it was determined the facility failed to ensure a resident who was admitted with limited range of motion was provided services to improve range of motion for one (#52) of two sampled residents who were reviewed for range of motion. The facility identified five residents who had decreased range of motion. Findings: Resident #52 was admitted on [DATE] and had diagnoses which included right above the knee amputation and peripheral vascular disease. A physician order, dated 04/05/21, documented, .Activity Status: UP AS TOLERATED .MAY USE WHEELCHAIR FOR MOBILITY PURPOSES . An admission assessment, dated 04/13/21, documented the resident was cognitively intact for daily decision making, had impairment in range of motion on one side of the lower extremities, used a wheelchair, required limited assistance of one person for transfers, was only able to stabilize herself with the assistance of one staff member when moving from a seated to a standing position, when moving on and off 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to: a) Provide an accessible egress from a resident's room for one (#44) of 21 residents observed for accident hazards, and b) Secure stored chemicals and used razors in a manner to prevent resident accessibility. The facility census and conditions report documented 66 residents resided in the facility. Findings: A facility policy, dated 02/21/20, and titled, Chemical Storage, documented, .All chemicals are a hazard risk to Resident's who may not be aware of what they are and what they are used for and that they may be poisoness [sic] .It is the policy of the Broken Arrow Nursing Home that all chemicals will be kept behind locked doors in an area that cannot be accessed by any Resident . 1. Resident #44 was admitted to the facility with diagnoses which included Reyes' syndrome, major depressive disorder, pseudobulbar affect, and had a feeding tube. An annual assessment, dated 06/21/20, documented the resident was severely…

    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 before2021-05-19 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure a gradual dose reduction ordered by a physician was completed for one (#62) of five residents reviewed for medications. The census and conditions report documented 52 residents received psychotropic medications. Findings: Resident #62 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia and major depression. The quarterly assessment, dated 10/17/20, documented the resident was independent for daily decision-making, had symptoms of psychosis, and had behaviors toward others. The care plan, dated 11/25/20, documented the resident's behavior patterns, psychotropic medications, and symptoms to monitor. The physician orders for May 2021 documented an order for Trazadone 25 milligrams (mg) at bedtime for insomnia. A pharmacy consultation report for March 2021 documented a recommendation for Trazadone 25 mg to be gradually reduced. The report documented the physician agreed and 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-05-19 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined the facility failed to ensure clinical records were complete for two (#44 and #167) of 23 sampled residents whose records were reviewed. This had the potential to affect all 66 residents who resided in the facility. Findings: 1. Resident #167 had diagnoses which included cerebral infarction and malignant neoplasm of the prostate. A nurse note, dated 07/26/20, documented the resident had pulled his peg tube out and the nurse replaced the peg tube. The note did not document the physician had been notified. Review of the resident's physician orders did not reveal an order had been obtained for the replacement of the peg tube. On 05/18/21 at 2:35 p.m., MDS (minimum data set) coordinator #1 was asked about the resident's peg tube being replaced. She stated she was working the day the peg tube had been pulled out. She stated the nurse on duty had notified the physician and replaced the peg tube. She was asked where physician notification and the order to replace the peg tube was documented. She stated she would review the clinical…

    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 · E2021-05-19 · tag F0943 — pattern
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record reviewd, it was determined the facility failed to provide abuse training for three of seven employees whose files were reviewed. The facility identified 11 new employees who had been hired since January 2021. Findings: The files for certified nurse aide (CNA) #8, CNA #9, CNA #3 were reviewed and did not document abuse training on hire for the CNAs. On 05/13/21 at 2:04 p.m., licensed practical nurse #3 stated he was not able to complete all the items for the employee file. The nurse stated it was not complete because they had not finished the employees' orientations.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-19 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    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 interview and record review, it was determined the facility failed to develop and implement the discharge planning process for one (#1) of three residents who were reviewed for discharge planning. The facility identified 15 residents who discharged in the last 60 days. Findings: Resident #1 discharged from the facility on 02/13/21 with diagnoses which included atrial fibrillation, muscle weakness, peripheral vascular disease, and chronic pain. A nurse's note, dated 02/13/21 at 12:26 p.m., documented, Resident's niece, [niece's name omitted], here to take resident home. Resident discharged with meds and belongings. This nurse educated niece on medications, dosages, and times administered. On 05/18/21 at 3:00 p.m., the clinical record for resident #1 was reviewed. There was no documentation of the resident's discharge planning. The care plan was reviewed. There was no care plan related to discharge needs and goals. On 05/18/21 at 4:00 p.m., the assistant Director of Nurses (ADON) was asked to provide 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-19 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 interview and record review, it was determined the facility failed to document a discharge summary for one (#1) of three residents whose discharge summaries were reviewed. The facility identified 15 residents who discharged in the last 60 days. Findings: Resident #1 discharged from the facility on 02/13/21 with diagnoses which included atrial fibrillation, muscle weakness, peripheral vascular disease, and chronic pain. A nurse's note, dated 02/13/21 at 12:26 p.m., documented, Resident's niece, [niece's name omitted], here to take resident home. Resident discharged with meds and belongings. This nurse educated niece on medications, dosages, and times administered. On 05/18/21 at 3:00 p.m., the clinical record for resident #1 was reviewed. On 05/18/21 at 4:00 p.m., the assistant Director of Nurses (ADON) was asked to provide any documentation related to the resident's discharge. The ADON returned with the resident's closed record and a sheet of paper with a section titled discharge summary. The discharge…

    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

“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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
COOPER, JOANNAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 04/01/1990
POORMON, PAULIEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL6%since 07/01/1995
WOODARD, DEBRAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER6%since 07/01/1995

CMS files one row per role, so the 10 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.4M
Net patient revenuemost recent cost report
-6.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 72%Medicare 2%Other / private 26%

About 72% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$254per resident / day
operating cost
$7,723per month
≈ monthly operating cost
$239per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

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 375565. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-01, 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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