Broken Bow Health and Rehab
700 West Jones, Broken Bow, OK 74728 · For profit - Partnership · 105 certified beds · (580) 584-6433 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $21,828 in federal fines (most recent 2026-05-21)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (66%) runs well above the national median (45%)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.8% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.9% | 3.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 7.6% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 5.7% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 3.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 4.7% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.2% | 13.7% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 18.8% | 25.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 96.2% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.7% | 17.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.1% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 62.2% | 74.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 28.4% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 31.5% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.23 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 6.80 | 2.96 | 1.80 | worse |
* 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.
55.9% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 32.4% 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 37 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.9%CMS range 42.4–69.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 8.3–18.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 32.4% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 43.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 21.6% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 94.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 4.3–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 105 beds and averages 63.2 residents a day — about 60% occupied, or roughly 42 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.11 hrs/resident/day on weekends vs 3.36 on weekdays — 8% thinner on weekends. RN hours go from 0.58 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 66% 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
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.
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.
36 citations, most serious first. The 12 most serious are shown; the remaining 24 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-05-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (#3) of 3 sampled residents reviewed for accidents/hazards. Resident #3 exited the facility and ended up at a fast food restaurant after crossing a busy, four-lane highway. The ADON identified 62 residents resided in the facility and one resident was identified as high risk for wandering. On 05/19/26 at 12:40 p.m., an IJ situation was determined to exist related to the facility's failure to provide adequate supervision for Resident #3, who was determined to have a high risk for wandering, and had prior history of elopement. On 05/19/26 at 5:09 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/19/26 at 5:23 p.m., the administrator, DON, and ADON was notified of the IJ situation and was provided the IJ template. On 05/20/26 at 2:01 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-08-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident was transferred properly to prevent a fall with major injury for one (#2) of three sampled residents who were reviewed for falls. CNA #3 transferred Res #2 without the required assistance of another staff member resulting in a fall with a fracture to Res #2's left tibula/fibula. The Resident Census and Conditions of Residents, dated 08/24/23 documented 44 residents required assistance with transfers. Findings: A Limited Lift Resident Handling Policy, dated January 2017, read in part, .The transfers will be designated into one of the following categories .2 or equivalent = 2-person transfer .Resident transfer status will be tagged in the resident's room to inform the staff of the appropriate transfer to use . Res #2 was admitted with diagnoses which included age-related osteoporosis, intellectual disabilities, dementia, legal blindness, and convulsions. Res #2's ADL care plan, dated 05/23/23, documented Res #2 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.
- Potential for harm · Ecited before2026-05-21 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive care plan was updated after a wandering risk scale increased to high risk for 1 (#3) of 3 sampled residents reviewed for wandering and elopement risk. The ADON identified 62 residents resided in the facility. Findings: A care plan for Resident #3, dated 03/22/26, showed the resident had impaired cognition, but showed no interventions for wandering risks. A Wandering Risk Scale for Resident #3, dated 03/23/26, showed the resident was at low risk for wandering. The document showed the resident had no history of wandering but did have cognitive impairment. An admission assessment for Resident #3, dated 03/27/26, showed the resident was admitted on [DATE] with diagnoses which included dementia, delirium, and head injury. The assessment showed the resident had a BIMS score of 11 which indicated moderate cognitive impairment. A Wandering Risk Scale for Resident #3, dated 04/22/26, showed the resident was a high risk for wandering. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-21 · tag F0770 — failed to provide lab services — patternProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to obtain hemoglobin A1c lab as ordered for 1 (#5) of 3 sampled residents reviewed for assess, monitor, and intervene.The ADON identified 62 residents resided in the facility. Findings:A facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, revised 11/2018, read in part, The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.The staff will process test requisitions and arrange for tests.A physician's order Resident #5's , dated 01/02/17, showed hemoglobin A1c (a blood sugar test) due in January, April, July, and October.Laboratory results Resident #5 were reviewed for January and April 2026. There was no documentation the tests were obtained.A physician's progress note for Resident #5, dated 05/18/26, read in part, We need an A1C with this patients labs every 90 days. Has been missed twice in a row now.On 05/21/26 at 8:37 a.m., LPN #1 stated if a resident had an order for lab, they would fill out a requisition form and lab would be collected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-08-26 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
On 08/21/25, an IJ situation was determined to exist related to the facilities failure to provide pharmacy services for Resident #1 in a timely manner.The facility was notified on 08/21/25 at 5:30 p.m., the Oklahoma State Department of Health was notified of the existence of an Immediate Jeopardy situation. On 08/21/25 at 5:38 p.m., the DON and administrator were notified of the existence of an IJ situation related to pharmacy services for Resident #1 . The IJ template was provided to administrator.On 08/23/25 at 9:26 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Removal of Immediate Jeopardy StatementFacility Name: Broken Bow Health And Rehab Date IJ Identified: August 21, 2025 Resident Affected: Resident #1Actions Taken to Remove the Immediate JeopardyUpon discovery, the facility immediately implemented the following corrective actions to mitigate risk and remove the Immediate Jeopardy:Resident-Centered Interventions-Resident #1 continues on current medication regiment with current cancer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-26 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 3 (#1, #2 and #3) of 3 sampled treatment carts were locked.The DON reported 61 residents resided in the facility.Findings:On 08/19/25 at 2:26 p.m., treatment cart #1 was observed to be on the left side of the nurse's station unlocked and unsupervised.On 08/19/25 at 2:27 p.m., treatment cart #2 was observed to be on the right side of the nurse's station unlocked and unsupervised.On 08/19/25 at 2:28 p.m., treatment cart #3 (wound care cart) was observed to be at the front entrance by the ADON office unlocked.A facility policy titled Security of Medication Cart, revised 04/2007, read in part, 1. The nurse must secure the medication cart during pass to prevent unauthorized entry .4. Medication carts must be securely locked at all times when out of the nurse's view .5. When the medication cart is not being used, it must be locked and parked.On 08/19/25 at 2:25 p.m. LPN #2 was observed walking away from the unlocked treatment cart. They walked into a medication supply closet and closed the door. There 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.
- Potential for harm · Dcited before2025-08-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a care plan was updated for 1 (#1) of 3 sampled residents reviewed for care plan.The DON reported 61 residents resided in the facility.Findings:A facility policy titled Care Plan, Comprehensive Person-Centered, dated December 2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of resident are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition;A physician consultation note for Resident #1, dated 03/24/25, read in part, Principal Diagnosis: Breast Cancer.A care plan for Resident #1, dated 05/27/25, showed no interventions or diagnosis for cancer was updated on the most recent care plan.On 08/21/25 at 10:51 a.m., the ADON reviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-26 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident who missed 77 cancer medications was included quality assurance and program improvement for 1 (#1) of 3 sampled residents reviewed for medication administration.The DON reported 61 residents resided in the facility.Findings:A facility policy titled Quality Assurance and Performance Improvement, revised 02/2020, read in part, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed . Coordination 2. The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessments methodologies and documentation, and in making adjustments to plan.On 08/19/25 at 11:19 a.m., the ADON stated how could they QAPI for the cancer medication we did not know about.On 08/26/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-12 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure MDS assessments had been completed accurately for two (#10 and #12) of 15 sampled residents reviewed for MDS accuracy. A daily census, dated 12/09/24, documented 57 residents resided at the facility. Findings: A facility policy titled Certifying Accuracy of the Resident Assessment, dated November 2019, read in part, The information captured on the assessment reflects the status of the resident during the observation period (look back) period for the assessment. 1. An active physician's order, dated 02/09/24, documented Resident #10 was admitted to long term care under the care a contracted hospice provider. A significant change assessment, dated 02/09/24, documented Resident #10 did not receive hospice services. An active physician's order, dated 09/14/24, documented staff were to assess and document the resident's status and collaborate with a contracted hospice provider. A quarterly MDS assessment, dated 11/11/24, documented in Section O that Resident #10 did not receive hospice services. On 12/11/24 at 2:00 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-12 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide ADL assistance with showers/baths for one (#9) of one sampled resident reviewed for ADL assistance. The administrator identified 55 residents resided in the facility. Findings: A policy titled Bath, Shower/Tub read in part, Documentation 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual (s) who assisted the resident with the shower/tub bath .Reporting 1. Notify the supervisor if the resident refused the shower/tub bath. Resident #9 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction and aphasia and dysphagia following a cerebral infarction. The care plan, dated 03/01/22, documented the staff were to assist the resident with a bath at least three times a week and per the resident's request. The care plan documented the resident was a two person assist with shower transfers. A quarterly assessment, dated 09/13/24, documented the resident had modified independent for daily decision making. It was documented the resident required moderate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-12 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident did not receive an antipsychotic that had been discontinued by a physician for one (#12) of five sampled residents reviewed for unnecessary medications. The DON identified eight residents in the facility were prescribed antipsychotic medications. Findings: A facility policy titled Medication and Treatment Orders, dated July 2016, read in part, Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Resident #12 had diagnoses which included major depressive disorder with psychotic features. A medication order, dated 10/08/22, documented Resident #12 was to have been administered Risperdal [an antipsychotic medication] 0.5 mg once daily. A document titled Pharmaceutical Consultant Report, dated 07/17/24, documented a pharmacist recommendation to reduce the dose of four psychotropic medications which included Risperdal 0.5 mg once daily and Risperdal 1 mg once daily. The report also documented a physician's response…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 dish machine temperature and sanitizer concentration was monitored and logged daily, kitchen equipment functioned properly, and food was stored in an appropriate manner. The administrator identified 54 residents received meals from the kitchen. Findings: An initial tour of the kitchen was conducted on 12/09/24 at 2:45 p.m. The following observations were made: a. the paper towel dispenser at the handwashing sink was not functioning; b. the Dish Machine Temperature Log, for December 2024 did not document the temperature or the concentration of sanitizer for 12/05/24, 12/06/24, 12/07/24, 12/08/24, or 12/09/24; c. there were two opened bottles of prune juice with no received on date or opened date; d. there were 10 individual sized cups of ranch dressing with no date of preparation; e. there was an opened 32-ounce carton of whole eggs with no received on or opened date; f. there was an opened uncovered can of pudding with no received on or opened date; g. there was an opened uncovered bulk container of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 24 citations
- Potential for harm · E2024-12-12 · tag F0880 — failed to prevent and control infections — patternProvide 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 plant to prevent the spread of water borne pathogens. The administrator reported the census was 55. Findings: A facility policy titled Legionella Surveillance and Detection, read in part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella .Legionnaire's disease will be included as part of our infection surveillance activities. On 12/12/24 at 7:53 a.m., the administrator reported they were unable to locate any documentation of monitoring for water-borne pathogens.
- Potential for harm · D2024-12-12 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to assess a resident for self-administration of medication for one (#54) of one sampled resident who was reviewed to self-administer medication. The administrator identified three residents who self-administered medications. Findings: A policy titled Self-Administration of Medication read in part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .If it is deemed safe and appropriate for the resident to self-administer medications, this is documented in the medical record and the care plan .Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. Resident #54 had diagnoses which included chronic obstructive pulmonary disease, reflux disease, and legal blindness.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 record review and interview, the facility failed to ensure medical records were accurate for one (#34) of two sampled residents reviewed for pressure ulcers. The administrator reported the facility census was 55. Findings: A facility policy titled Charting and Documentation, read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record .Treatments or services performed. Resident #34 had diagnoses which included congestive heart failure and urinary incontinence. An admission assessment, dated 11/13/24, documented Resident #34 had one stage II and two stage III pressure ulcers that were present upon admission. A physician's order, dated 11/09/24, documented Resident #34 was to receive wound care to the left ankle daily. A physicians orders, dated 11/21/24, documented Resident #34 was to receive wound care to the left heel daily 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.
- Potential for harm · E2024-11-26 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for one (#5) of five sampled residents reviewed for medication administration. The administrator identified 56 residents who resided in the facility. Findings: Resident #5 had diagnoses which included epileptic seizures, cerebral infarction, and cognitive communication deficit. The care plan, dated 12/04/19, documented the resident had a history of a seizure disorder. The care plan documented the staff were to administer seizure medication as ordered by the physician. The quarterly assessment, dated 08/20/24, documented the resident was severely impaired for daily decision making and was dependent with activities of daily living. A physician order, dated 09/28/24, documented the resident was to receive phenytoin (an anticonvulsant medication) 125 mg/5 ml and give 5 ml via peg tube daily for seizures. The MAR for November 2024 documented the resident did not receive the phenytoin medication seven out of 25 opportunities. On 11/25/24 at 3:05 p.m., the DON reviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-26 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure 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, record review, and interview, the facility failed to provide snacks between meal times for two (#2 and #4) of two sampled residents reviewed for snacks provided between meals. The administrator identified 56 residents resided in the facility. Findings: A facility policy titled Snacks (Between Meal and Bedtime), Serving read in part, purpose of this procedure is to provide the resident with adequate nutrition .Arrange the snack so that it can be easily reached by the resident .Notify the supervisor if the resident refuses the snack and why. 1. Resident #2 had diagnoses which included cerebrovascular disease, dysphagia, and aphasia. The admission assessment, dated 09/02/24, documented the resident was cognitively intact and required setup assistance with eating. The assessment documented it was very important to the resident to have snacks available between meals. On 11/26/24 at 8:32 a.m., Resident #2 stated if they were hungry between meals they would like to have a snack. 2. Resident #4 had diagnoses which included cerebral infarction, muscle weakness, 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.
- Potential for harm · E2023-08-31 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure residents who received meals from the kitchen were served in a timely manner and avoided the daily use of disposable cutlery for 38 residents sampled for respect and dignity. The DON reported 58 residents received meals from the kitchen. Findings: A document, titled Complaints Resident Council, dated 08/10/23, documented in part, .meals served later and later everyday . Resident Council Minutes, dated 06/22/23, documented in part, .certain residents always get real plates no matter what and residents are tired of using plastic silverware . On 08/24/23 at 8:45 a.m., a sign in the dining room, by the kitchen window, documented breakfast at 8:00, lunch at 12:30, and dinner at 4:30. On 08/24/23 at 9:00 a.m., 19 residents were in the dining room, one resident had been served food. Staff were assisting three residents with being seated in the dining room. On 08/24/23 at 9:10 a.m., 19 residents had food and staff were assisting residents entering the dining room. On 08/24/23 at 9:15 a.m., Dietary Aide #1 reported it wasn't…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-31 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure floors were cleaned in two (#107 and #108) of two resident rooms sampled for a clean, homelike environment. The Resident Census and Conditions of Residents, dated 08/27/23, documented a census of 58 residents. Findings: A document, titled Complaints Resident Council, dated 08/10/23, documented in part, .floors are dirty. Made by all 12 . On 08/29/23 at 7:17 a.m., an unidentified housekeeping staff member was observed mopping room [ROOM NUMBER] and placing a wet floor sign in the doorway of room [ROOM NUMBER]. The floor of room [ROOM NUMBER] was observed to be wet upon entry by the surveyor. Three rolls of toilet tissue, two plastic spoons, and a straw were on the floor between the resident's bed and the wall. A potato chip bag and a pink plastic bottle were under the resident's bed. The DON was summoned to room [ROOM NUMBER] by the surveyor. The DON stated the room did not appear to have been cleaned. The DON stated if the floor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-31 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide monthly drug regime reviews for three (#7, 15 and #46) of three sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents, dated 08/24/23 documented a census of 58 residents. Findings: 1. Res #7 was admitted with diagnoses which included anxiety and depression. The DON was unable to provide a monthly drug regime review for May and June of 2023. 2. Res #46 was admitted with diagnoses which included schizoaffective disorder, bipolar type brief psychotic disorder and schizophrenia. The DON was unable to provide a monthly drug regime review for March, April and June of 2023. On 08/31/23 at 2:05 p.m., the Corp Nurse Consultant reported the staff could not locate a monthly drug regime review for every month for the past year. The Corp Nurse Consultant reported scanning was backed up and it was difficult to locate the required documents. 3. Res #15 was admitted to the facility on [DATE] and had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation,record review, and interview, the facility failed to ensure residents received showers/baths as scheduled for two (#24 and #43) of two residents sampled for showers/baths. The Residents Census and Conditions of Residents, dated 08/24/23, documented 57 residents required assistance with showers/baths. Findings: 1. Res #24 was admitted with diagnoses which included multiple sclerosis, urinary incontinence, and obesity. A quarterly assessment, dated 06/25/23, documented Res #24 required physical assistance with bathing. A care plan, last updated on 08/17/23, documented Res #24 required two staff in the shower room and limited assistance with bathing three times weekly. A bathing record, dated 08/01/23 to 08/31/23, documented Res #24 had seven missed opportunities for bathing. On 08/28/23 at 9:40 a.m., Res #24 reported they had not received showers as scheduled. On 08/31/23 at 9:46 a.m., the ADON reviewed Res #24's bathing record. The ADON reported the documentation showed Res #24 had received six showers and had seven missed opportunities. The ADON reported the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure pressure ulcer treatments were performed as ordered by the physician for one (#37) of two sampled residents reviewed for pressure ulcers. The Resident Census and Condition of Residents form documented one resident had pressure ulcers. Findings: Res #37 had diagnoses which included pressure ulcer of sacral region stage IV, fracture of neck of left femur, subsequent encounter for closed fracture with routine healing, chronic kidney disease, COPD, protein-calorie malnutrition, DM, and rheumatoid arthritis. A physician order, dated 06/26/23, documented to cleanse wound to sacrum with wound cleanser, pat dry with gauze, pack with Dakin's soaked kerlix, and cover with bordered dressing two times a day. The order was discontinued on 07/05/23. A physician order, dated 06/29/23, documented to paint left heel blister with Betadine one time a day for blister. The order was discontinued on 07/18/23. The June 2023 wound treatment record showed three missed treatments out of nine opportunities to the sacrum 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.
- Potential for harm · D2023-08-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure one (#34 ) of one resident sampled for catheter care received indwelling catheter care as ordered by the physician. The Resident Census and Conditions of Residents, dated 08/24/23, documented three residents with indwelling urinary catheters. Findings: Res #34 was admitted with diagnoses which included paraplegia and neuro-muscular dysfunction of the bladder. A physician's order, dated 01/05/23, documented to provide catheter care every shift. A physician's order, dated 07/03/23, documented to change the catheter bag every Sunday on evening shift. A quarterly assessment, dated 08/03/23, documented Res #34 had an indwelling urinary catheter. A physician order, dated 08/03/23, documented levofloxacin (an antibiotic) 750 milligrams to be administered one time a day for three days for urinary tract infection. The August 2023 TAR documented Res 34's catheter bag was not changed as ordered on 08/13/23, 08/21/23, 08/24/23, and 08/27/23. On 08/30/23 at 2:38 p.m., LPN #2 reported they had not performed catheter care for Res…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the physician was notified of significant weight loss and implement interventions to maintain and/or prevent further weight loss for two (#7 and #44) of two sampled resident reviewed for weight loss. The Resident Census and Conditions of Residents, dated 08/24/23 documented a census of 58 residents. Findings: 1. Res #7 was admitted with diagnoses which included anxiety and depression. On 08/27/23 at 12:45 p.m., Res #7 was observed eating independently in the dining room. The Weight Assessment and Intervention policy, last revised September 2008, read in part, .Any weight change of 5% or more .nursing will immediately notify the dietician in writing. Verbal notification must be confirmed in writing. The dietician will respond within 24 hours of receipt of written notification .negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met .Individualized care plans…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure physician orders were followed related to: a. the administration of warfarin (an anticoagulant), b. FSBS screening and sliding scale insulin administration, and c. notifying the physician of FSBS results over 400 for one (#37) of five sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 15 residents received injections. Findings: Res #37 had diagnoses which included fracture of neck of left femur, subsequent encounter for closed fracture with routine healing, personal history of other venous thrombosis and embolism, hereditary deficiency of other clotting factors, atherosclerotic heart disease of native coronary artery without angina pectoris, and DM. A physician order, dated 06/25/23, documented to inject NovoLog insulin subcutaneously before meals and at bedtime related to DM per the following sliding scale: FSBS 200 - 250 = 4 U; FSBS 251 - 300 = 6 U; FSBS 301 - 350 = 8 U; FSBS 351 - 400 = 10 U; FSBS 401 - 450 = 12 U If greater than 400…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-29 · tag F0656 — failed to write and follow a full care plan — widespreadDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to develop a comprehensive person centered care plan on five (#32, 36, 38, 44 and #51) of five residents sampled for care plans. The Residents Census and Conditions of Residents documented 56 residents resided in the facility. Findings: A policy and procedure, revised 12/2016, titled Care Plans, Comprehensive Person-Centered read in part, Assessments of resident are ongoing and care plans are revised as information about the residents and residents' conditions change . 1. Res #32 was admitted with diagnoses which included dementia, hypertension, and cachexia. A physician's order, dated 07/14/22 at 3:00 p.m., documented paint blister to right heel with betadine until resolved, every shift for healing. A significant change assessment, dated 07/19/22, documented Res #32 was severely cognitively impaired and required extensive assistance with activities of daily living. A care plan, dated 07/27/22, was reviewed and the stage two pressure injury had not been care planned. A progress note, dated 07/29/22 at 2:41 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-09-29 · tag F0578 — failed to honor advance directives / code status — patternHonor 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to provide an advance directive acknowledgment for three (#26, 32, and #36) of three residents sampled for advance directives. The Resident Census and Conditions of Residents documented 56 residents resided in the facility. Findings: Upon review of residents' electronic health record, an advance directive acknowledgment was not documented on residents #26, 32, and #36. A policy titled, Advance Directives revised on 12/2016, read in part .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . On 09/28/22 at 8:30 a.m., the corporate RN stated the advance directive acknowledgments were not provided to the residents.
- Potential for harm · Ecited before2022-09-29 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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 resident assessments were completed accurately for four (#30, 45, 52 and #56) of five residents whose assessments were reviewed for accuracy. The Resident Census and Conditions of Residents dated, 09/26/22, documented 58 residents resided in the facility. Findings: 1. Res #30 was admitted with diagnoses which included scoliosis. A comprehensive care plan dated, 07/30/21, documented in part, I have bed rails/enabler bars per my request to assist me with bed mobility . An annual resident assessment, dated, 10/15/21, documented in error side rails were used daily as a restraint. A quarterly resident assessment, dated, 01/15/22, documented in error side rails were used daily as a restraint. A quarterly resident assessment, dated, 04/17/22, documented in error side rails were used daily as a restraint. A quarterly resident assessment, dated, 07/18/22, documented in error side rails were used daily as a restraint. On 09/26/22 at 8:21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-09-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to prepare pureed meals in a sanitary manner. Cook #1 reported five residents received pureed meals from the kitchen. Findings: On 09/27/22 at 11:10 a.m., [NAME] #1 was observed preparing pureed meals. On 09/27/22 at 11:12 a.m., [NAME] #1 placed the blender bowl on the preparation table. On 09/27/22 at 11:13 a.m., [NAME] #1 donned gloves. On 09/27/22 at 11:15 a.m., [NAME] #1 was observed scratching their arm and proceeded to obtain sandwiches from a plate and place them in the blender bowl. On 09/27/22 at 11:20 a.m.,Cook #1 carried the blender bowl to the dishwasher, washed and returned the blender bowl to the base, and proceeded to puree potato salad. The cook did not perform hand hygiene or change gloves. On 09/27/22 at 11:30 a.m., [NAME] #1 reported they should have performed hand hygiene and changed gloves. On 09/27/22 at 11:35 a.m., the DM reported the cook had been in-serviced on infection control and should have changed gloves and performed hand hygiene.
- Potential for harm · E2022-09-29 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to develop and implement an antibiotic stewardship program. The Resident Census and Conditions of Residents, dated 09/26/22, documented two residents were receiving antibiotics. Findings: The Antibiotic Stewardship policy, revised 12/2016, documented in parts, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program .the purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents .The IP will monitor .and report to the IPCC (Infection Prevention and Control Committee) . Reviewed Antibiotic Stewardship binder, documentation ended on 07/22. On 09/27/22 at 3:35 p.m., the corporate RN reported antibiotic stewardship data had not been collected since 07/22. She reported the data had not been trended or reported to the QAPI committee. On 09/28/22 at 9:23 a.m., the IP stated the antibiotic stewardship data wasn't current.
- Potential for harm · D2022-09-29 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a baseline care plan for one (#61) of two residents reviewed for baseline care plans. The Resident Census and Conditions of Residents, dated 09/26/22, documented 56 residents resided in the facility. Findings: Res #61 was admitted on [DATE] with diagnoses which included malignant cancer of the lung. A physician's order, dated 07/14/22, documented in parts . morphine sulfate (a pain medication)100mg/5ml give 1 ml by mouth every 2 hours for pain .lorazepam (an anti-anxiety medication) 0.5 mg, give 1 tablet by mouth 2 times a day for anxiety. During a review of Res #61's electronic health records, a care plan was not located. On 09/28/22, the corporate RN reported Res #61 did not have a base line care plan.
- Potential for harm · Dcited before2022-09-29 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to revise a care plan for one (#44) of one residents sampled for care plans. The Residents Census and Conditions of Residents, dated 09/26/22, documented two residents received peg tube feedings in the facility. Findings: Res #44 was admitted with diagnoses which included Alzheimer's and dysphagia. A policy and procedure, revised 12/2016, titled Care Plans, Comprehensive Person-Centered, documented in part . Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change . A physician's order, dated 08/19/22, documented, Osmolite 1.5 Cal Liquid (nutritional supplements[sic]) give 180 ml via peg tube four times a day for supplement. A quarterly assessment, dated 08/20/22, documented Res #44 required tube feedings. A care plan, revised on 09/13/22, documented, Osmolite 1.5 cal via peg tube five times a day. On 09/26/22 at 3:45 p.m., Res #44 was observed receiving a feeding via the peg tube. On 09/27/22 at 3:15 p.m., the corporate nurse reported…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-29 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure discharge summaries were completed for two (#2 and #62) of three residents reviewed for discharge summaries. The DON reported 35 residents had been discharged from the facility in the past six months. Findings: 1. Res #2 was admitted on [DATE]. A progress note, dated 07/09/22, documented Res #2 was discharged to home with family. 2. Res #62 was admitted on [DATE]. A progress note, dated 07/27/22, documented Res #62 was discharged to home. The Discharge Summary and Plan policy, revised 12/16, documented in parts .a discharge summary and a post-discharge plans [sic] will be developed to assist the resident to adjust to his/her new living environment .will include a recapitulation of the resident's stay .every resident will be evaluated for his or her discharge needs and will have an individualized discharge plan. On 09/28/22 at 9:10 a.m., the corporate RN reported discharge summaries had not been completed for residents #2 and #62.
- Potential for harm · D2022-09-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was labeled with a change date and to obtain a physician's order for oxygen tubing changes for two (#36 and #52) of three residents reviewed for oxygen therapy. The DON reported 14 residents were receiving oxygen therapy. Findings: A policy and procedure, revised 10/2010, Oxygen Administration did not document how often the tubing should have been changed or if the tubing should have been labeled. 1. Res #36 was admitted with diagnoses which included respiratory failure and dyspnea. There was no physician's order for changing the oxygen tubing. A physician's order, dated 08/26/22, documented, oxygen via nasal cannula to be turned above 4 liter per minute every shift for supplement. On 09/26/22 at 10:42 a.m., Res #36 was observed in bed with oxygen in use. The oxygen tubing was not labeled or dated. Res #36 stated they were not sure how often their oxygen tubing was changed. On 09/26/22 at 3:43 p.m., Res #36 was observed with oxygen in use. The oxygen tubing was not labeled or dated. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-29 · tag F0700 — isolatedTry 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 perform interdisciplinary assessments on two (#38 and #44) of two residents reviewed for side rails. The DON reported ten residents required side rails. Findings: A Bed Safety Policy, revised 12/07, documented in part, If side rails are used, there shall be an interdisciplinary assessment of the resident . 1. Res #38 was admitted with diagnoses which included intracranial injury and chronic obstructive pulmonary disease. A significant change assessment, dated 07/25/22, documented Res #38 was severely cognitively impaired, required extensive assistance with activities of daily living, and used side rails daily. The electronic health record was reviewed and did not contain documentation of a side rail assessment, or a care plan for side rails. On 09/26/22 at 10:52 a.m., Res #38 was observed in bed with half side rails raised on both sides. 2. Res #44 was admitted with diagnoses which included Alzheimer's and cerebral infarction. A quarterly assessment, dated 08/20/22, 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.
- Potential for harm · D2022-09-29 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly 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 document side rail maintenance for two (#38 and #44) of two residents sampled for side rails. The DON reported ten residents required side rails. Findings: The Bed Safety policy, revised 12/07, documented in parts .To try to prevent death/injury from the beds .inspection by maintenance staff of all beds .as part of our regular bed safety program .ensure that bed side rails are properly installed .the maintenance department shall provide a copy of the inspections to the administrator . 1. Res #38 was admitted with diagnoses which included intracranial injury and chronic obstructive pulmonary disease. A significant change assessment, dated 07/25/22, documented Res #38 was severely cognitively impaired, required extensive assistance with activities of daily living, and used side rails daily. The electronic health record did not contain side rail maintenance documentation. On 09/26/22 at 10:52 a.m., Res #38 was observed in bed with half side rails up on both sides. 2. Res #44 was admitted with diagnoses which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$21,828 in federal fines across 2 penalties.
- $14,385 — penalty dated 2026-05-21
- $7,443 — penalty dated 2023-08-31
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GRANT RHODES REVOCABLE TRUST DATED JANUARY 30, 2018 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 25% | since 05/01/2022 |
| JACK L BYERS REVOCABLE TRUST DATED JANUARY 26, 2017 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 25% | since 05/01/2022 |
| JEFFREY W YOUNG REVOCABLE TRUST DATED JULY 27, 2017 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 25% | since 05/01/2022 |
| SNOW FAMILY TRUST DATED JUNE 29, 2012 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 25% | since 05/01/2022 |
| BYERS, JACK | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 25% | since 05/01/2022 |
| RHODES, JONATHAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 25% | since 05/01/2022 |
| SNOW, AUDREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 13% | since 05/01/2022 |
| SNOW, LARRY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 13% | since 05/01/2022 |
| YOUNG, BRIDGETTE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 13% | since 05/01/2022 |
| YOUNG, JEFFREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 13% | since 05/01/2017 |
| BEDLAM PROPERTIES HO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/22/2025 |
| MATRIX PROVIDER SOLUTIONS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/08/2025 |
| LIETZKE, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/27/2024 |
| WILLIAMS, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/11/2022 |
| BBHR PROPCO, LLC | Organization | ADP OF THE SNF | — | since 05/01/2022 |
| PEARSON, ARTHUR | Individual | ADP OF THE SNF | — | since 05/01/2022 |
CMS files one row per role, so the 32 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 83% 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 $763K paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375165. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-12, 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.