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Calera Manor

1061 North Access Road, Calera, OK 74730 · For profit - Limited Liability company · 82 certified beds · (580) 434-5727 Medicare & Medicaid certified

Call the home — (580) 434-5727 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609, F0610) — most recent Jun 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • 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 citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — 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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1014 Memorial Dr Ste 212 · (903) 416-6350 · Call to confirm hours
Pharmacy
401 N Us Highway 75 · (903) 465-8035 · Call to confirm hours
Grocery
103 South Franklin St · (580) 296-2009 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
PLATTER Dyke Rd

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 2 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.

Overall rating2★
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 increased11.2%13.6%15.4%better
Long-stay residents who lose too much weight2.7%3.3%5.4%better
Long-stay residents with a catheter left in their bladder6.5%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection7.3%2.8%2.0%worse
Long-stay residents with depressive symptoms0.0%3.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.4%4.7%3.3%better
Long-stay residents whose ability to walk worsened10.3%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.2%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.7%94.6%95.3%typical
Long-stay residents with pressure ulcers6.6%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control9.5%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table27.8%17.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication8.8%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine98.4%74.1%79.4%better
Short-stay residents rehospitalized after admission32.8%27.3%22.6%worse
Short-stay residents with an outpatient ER visit6.1%16.6%12.0%better
Long-stay hospitalizations per 1,000 resident days3.062.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.112.961.80better

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

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

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

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

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

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

39.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 167 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.9%U.S. median 51.5%
Got home and stayed home
17.3%U.S. median 10.7%
Went back to hospital
48.4%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 48.4% 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 64 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF39.9%CMS range 31.9–47.151.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF17.3%CMS range 13.7–20.710.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting93.9%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge93.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.6%CMS range 6.0–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.401.02Oct 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

0.13
RN hours/ resident / day
0.65
LPN hours/ resident / day
1.47
Aide hours/ resident / day
2.26
Total nurse hours/ resident / day
0.11
RN hoursweekends
42.2%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 82 beds and averages 78.6 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.13 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.47 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 1.91 hrs/resident/day on weekends vs 2.40 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.14 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2025-06-12)
11
at the previous standard inspection (2024-01-11)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Fcited before2025-06-12 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day. The DON identified 74 residents who resided in the facility. Findings: A PBJ Staffing Data Report, dated 01/01/25 through 03/31/25 (the second quarter of fiscal year 2025), showed the facility did not have RN coverage on 44 of the 90 days in that quarter. Below are the dates identified as not having RN coverage in January, February, and March 2025. a. January 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th, and 31st. b. February 2nd, 8th, 9th, 15th, 22nd, and 23rd. c. March 2nd, 15th, 16th, 22nd, 23rd, 29th, and 30th. On 06/10/25 at 1:46 p.m., the DON stated the facility did not have documentation of RN coverage for the dates listed on the facility's PBJ report. They stated the facility did not have registered nurses available to cover on those dates.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-12 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 did not receive antipsychotic medications for the diagnosis of dementia for 2 (#14 and #25) of 6 sampled residents reviewed for unnecessary medications. The DON stated 22 residents were prescribed antipsychotic medications at the facility. 1. A significant change MDS assessment, dated 03/09/25, showed in section C Res #14 had a BIMS score of 3 [this indicated the resident's cognition was severely impaired]. A policy titled Antipsychotic Medication Use, dated April 2007, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. A prescription order, dated 03/04/25, showed Res #14 had been prescribed one tablet of Seroquel [an antipsychotic medication] 50 mg every day for dementia with mood disturbance. A prescription order, dated 05/16/25, showed Res #14 had been prescribed one tablet of Risperdal [an antipsychotic medication] 1 mg each day for dementia with mood disturbance. On 06/11/25 at 2:42 p.m., the ADON…

    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 · D2025-06-12 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to notify the physician of a significant weight change for 1 (#71) of 3 sampled residents reviewed for nutrition. A weight variance report, dated 06/09/25, showed 4 residents with significant weight loss. Findings: An undated facility policy titled Weight and Height Measurement, read in part, Notify the charge nurse or physician of all weight changes of five pounds (or 5%) or more in a 30-day period or ten percent in a 180-day period or per state requirement. Review of the vital sign records for Res #71 showed their weight on: - 05/02/25 - 126.1 pounds, - 05/14/25 - 114.2 pounds, and - 05/27/25 - 109.4 pounds. A care plan intervention, implemented on 05/05/25, read in part. Monitor vital sign and weight as ordered, notify physician if there is a significant weight change. A Dietitian's Recommendations for Primary Care Provider form, dated 05/30/25, showed Res #71's weight had decreased from 126.1 pounds on 05/02/25 to 109.4 pounds in one month. The form also recommended 60 milliliters of TwoCal HN (a liquid nutritional…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 implement a comprehensive care plan intervention regarding smoking safety assessments for 1 (#25) of 18 sampled residents reviewed for care plans. The DON stated there were 74 residents resided in the facility. Findings: A facility policy titled Smoking Policy, undated, read in part, The nursing staff will conduct an assessment upon admission to establish guidelines for each resident who wished to smoke. The policy further read in part, Assessments will continue to be completed upon admission, quarterly and change in condition. A facility policy titled Care Plans - Comprehensive, dated 2010, read in part, Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. A care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a resident that smoked cigarettes was assessed for the ability to safely smoke for 1 (#25) of 4 sampled residents reviewed for accidents. The DON stated 15 residents at the facility smoked tobacco products. Findings: A facility policy titled, Smoking Policy, undated, read in part, The nursing staff will conduct an assessment upon admission to establish guidelines for each resident who wished to smoke. Any restrictions will be noted in the resident's record. The policy also read in part, Assessment will continue to be completed upon admission, quarterly, and change of condition, A care plan problem, dated 12/27/24, showed Res #25 was a smoker and at risk for injury. A correlated care plan intervention, dated 12/27/24, showed the nursing department was to conduct smoking assessments on Res #25. An annual MDS assessment for Res #25, dated 05/12/25, showed in section C, the resident had a BIMS score of 3 which indicated Res #25's cognition was severely impaired. On 06/10/25 at 1:01 p.m., LPN #1 was asked about Res #25'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to report an allegation of physical abuse to local law enforcement for 1 (#80) of 1 sampled resident reviewed for abuse. The assistant administrator reported the census in the facility was 74. Findings: A facility policy titled Abuse - Reportable Events, dated 08/19, read in part, All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. The policy further read in part, Local law enforcement will be notified of any reportable crime against a resident. An admission assessment, dated 05/11/24, showed Res #80 had a BIMS score (a test of cognitive function) of 15, which is indicative of intact cognition. An incident report form, dated 05/17/24, showed Res #80 reported an allegation of physical abuse to facility staff. The report also showed the physician, the resident's legal representative and adult protective services were notified. The report did not show local law enforcement had been notified. On 06/11/25 at 2:49 p.m., the DON stated they could not…

    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 · E2024-01-11 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient staff to provide supervision for one (#35) of 17 sampled residents reviewed for sufficient staffing. The administrator identified 67 residents resided in the facility and 23 resident were dependent on staff for assistance with activities of daily living. Findings: Resident #35 had diagnoses which included pain, dysphagia following cerebral infarction, and need for assistance with personal care. A Physician Order, dated 11/21/23, documented Resident #35 was to have nectar thick liquids. An admission assessment, dated 11/24/23, documented Resident #35 had no cognitive impairment, needed substantial assistance with toileting, showers, dressing, and personal hygiene, and had upper and lower extremity impairment. A Timecard Editor, dated 12/30/23, documented three staff clocked in on 10 p.m.-6 a.m. shift. A Timecard Editor, dated 01/05/24, documented three staff clocked in on 10 p.m.-6 a.m. shift. A Timecard Editor, dated 01/06/23, documented four staff clocked in on 10 p.m. -6 a.m. shift. On 01/10/24 at 2:37…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-11 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours per day. The administrator identified 67 residents resided in the facility. On 01/09/24 at 2:56 pm., RN coverage time sheets were reviewed with the Adm. Asst. from 10/01/23 through 10/31/23. There was no RN coverage for eight consecutive hours per day for the following dates: 10/03/23, 10/04/23, 10/05/23, 10/07/23, and 10/09/23 through 10/14/23. The Administrator acknowledged there was no RN coverage. A staff schedule, dated 12/25/23 through 01/13/24 did not have a Registered Nurse scheduled on 01/07/24. On 01/09/24 at 3:22 p.m., the Adm. Asst. was shown the staff schedule dated 12/25/23 through 01/13/23 and asked if there had been registered nurse coverage on 01/07/24. They reviewed the the payroll time on the computer and stated no RN had clocked in on that date. No further information was provided.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-11 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure: a. staff did not carry two resident's medications (#126 and #59) to administer at the same time, b. staff counted controlled medications every shift per policy, and c. controlled medications had accurate narcotic count sheets for two (#70 and #46) of four sampled residents reviewed for medications. The administrator identified 67 residents resided in the facility. The DON identified 35 residents received narcotics. Findings: An undated Narcotic Count policy, read in parts .To complete a physical inventory of narcotics at change of each shift by two licensed nurses to identify discrepancies and need for reconciliation and accountability .To assure controlled drugs are handled, stored .properly .To assure proper record keeping for controlled drugs .Narcotic records are reconciled by a physical count of the remaining narcotics supply at the change of each shift by the oncoming and outgoing licensed nurse .If the count is not accurate, the nurse going off duty is to remain on duty until the count is…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-11 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure snacks were offered to one [#8] of three sampled residents reviewed for snacks. The administrator identified 67 residents resided in the facility. Findings: The Snacks (Between Meal and Bedtime) policy, revised October 2010, read in part, .The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the snack was served. 2. The name and title of the individual(s) who served the snack. 3. The amount of the snack eaten by the resident(i.e., 50%, 75%, etc.). 4. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 5. Any special special request(s) made by the resident concerning his or her eating time or food likes and dislikes. 6. Any difficulty the resident had in feeding himself of herself, chewing or swallowing. 7. If the resident refused the snack, the reason(s) why and the intervention taken. 8. The signature and title of the person recording the data. On 1/10/24 at 1:27…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-01-11 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 informed consent was obtained for the use of an antipsychotic medication for one (#47) of five sampled residents reviewed for unnecessary meds. The Administrator identified 67 residents resided in the facility and the DON identified 22 residents who received psychotropic medications. Findings: Resident #47 had diagnoses which included saddle embolus of pulmonary artery, high blood pressure, and dementia. A five day assessment, dated 11/18/23, documented Resident #47 had severe cognitive impairment. The clinical health record did not contain documentation an informed consent had been signed for the use of Risperdal. A medication flowsheet, dated 11/01/23 through 11/30/23, documented to administer Risperidone one milligram in the am and two milligrams at hour of sleep. A Physician Order, dated 12/11/23, documented an increase for Risperidone to two milligrams in the morning. A medication flowsheet, dated 12/01/23 through 12/21/23, documented a dose change on 12/11/23 to two milligrams in the morning. On 01/09/24 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure privacy by preventing wandering residents from going in other residents' rooms uninvited for two (#23 and #25) of three sampled residents reviewed for privacy. The administrator identified 67 residents resided in the facility and the ADON identified seven residents that wandered. Findings: A 'Resident Rights' document, revised 08/2013, read in parts, .Privacy and confidentiality. The resident has the right to personal privacy .Personal privacy includes accommodations . 1. Resident #25 had diagnoses which included hypertension. On 01/04/24 at 2:22 p.m., Resident #25 reported there was a male resident that walks in their room all the time unwanted and drips snot everywhere. When asked what the facility had done to stop this from happening Resident #25 stated nothing, I tell them, and they just keep coming and getting him out. 2. Resident #23 had diagnoses which included hypothyroidism. On 01/04/24 at 2:57 p.m., Resident #23 reported there were unwanted residents that walked into their room all the time…

    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 before2024-01-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to report allegations of abuse to the State agencies for two (#36 and #63) of three sampled residents reviewed for abuse. The Administrator reported there were 67 residents residing in the facility. Findings: An Abuse - Reportable Events policy, dated 08/2019, read in parts, .1. The Charge nurse will: If a resident to resident incident occurs, staff should immediately intervene. Separate residents and take them to areas away from each other until the situation has subsided .Notify the repsonsible party/guardian and physician of each resident .2. The administrator will: Notify state agency as required . 1. A quarterly MDS for resident #63, dated 10/11/23, documented they had diagnoses that included hyperlipidemia and chronic kidney disease with a BIMS of 10. 2. A significant change MDS for resident #36, dated 01/03/23, documented they had diagnoses that included dementia and cognitive communication deficit with a BIMS of 02. A Nurse's Note, written by LPN #2 on 12/17/23, documented staff had to continuously separate Resident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to investigate allegations of inappropriate sexual behavior for two (#36 and #63) of three sampled residents reviewed for abuse. The Administrator identified there were 67 residents residing in the facility. Findings: An Abuse - Reportable Events policy, dated 08/2019, read in parts, .The facility administration will conduct and investigate allegations of .suspected abuse .Investigation .b. Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents . Resident #63 had diagnoses that included hyperlipidemia and chronic kidney disease. A quarterly MDS for Resident #63, dated 10/11/23, documented they had BIMS of 10. A Nurses Note, written by LPN #2, dated 12/17/23, documented staff had to continuously separate Resident #63 from rubbing on a female resident. On 01/08/24 at 10:18 a.m., LPN #2 acknowledged reporting incidents of a somewhat sexual nature between Resident #63 and Resident #36 to the charge nurse on duty at the time, but did not…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure showers were provided for one (#8) of two sampled residents reviewed for ADL assistance. The administrator identified 67 residents resided in the facility. Findings: Resident #8 had diagnoses that included Parkinson's disease, was wheelchair dependent, and required supervision and touch assistance for showers. On 01/09/24 at 12:15 p.m., Resident #8 reported they had not received a shower for the past three weeks. No showers were documented for Resident #8 for the following dates: 12/23/23, 12/26/23, 12/29/23, 01/01/24, 01/03/24, and 01/05/24. The last week of December for the bathing sheets, 3 out of 3 opportunities were missed. According the first week of January 2024 bathing sheets schedule, 3 out of 3 opportunities were missed. A facility shower list documented Resident #8 was to receive showers Monday, Wednesday, and Friday of each week. On 01/09/24 at 12:16 p.m., the ADON reviewed the showers that were documented for Resident #8 and acknowledged that showers had not been given as scheduled.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure supervision for a resident who was on a mechanically altered diet for one (#60) of 17 sampled residents. The administrator identified 67 residents resided in the facility and the DON reported four residents received a pureed diet and nineteen residents received a mechanical soft diet. Findings: A Safety and Supervision of Residents policy, revised December 2007, read in parts, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Implementing interventions to reduce accident risks and hazards shall include the following .ensuring that interventions are implemented . Resident #60 had diagnoses that included traumatic brain injury and dysphagia. Resident #60's care plan, dated 10/05/22, read in part, .was at risk for weight loss due to dysphagia .[Resident #60] must be removed after each meal and monitored by staff to prevent him from eating off of other resident's trays . The care plan had not been updated to contain any current interventions had been put…

    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 · D2024-01-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to maintain infection control during wound care for one (#19) of one sampled resident reviewed for wound care. The administrator identified 67 residents resided in the facility. The DON identified eight residents received wound care. Findings: An undated Dressing Change Guidelines, read in parts .The following is meant to be used as a guideline only and to promote the safe-and-effective use of the wound care products .ointments or medications should be placed in a clean contained (plastic med cup) which is to be brought into the room .Position resident .Don gloves, remove soiled dressings .Remove gloves wash hands .Don gloves .clean wound .Remove gloves wash hands .Don gloves for topical/dressing .apply with clean cotton tipped applicator . Resident #19 had diagnoses which included muscle wasting and atrophy, osteoarthritis, and depression. A Physician Order, dated 12/27/23, documented to cleanse the coccyx with normal saline, pat dry, apply medihoney and calcium alginate and cover with a dry dressing every day.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-10-21 · tag F0640 — widespread
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to transmit resident assessments to CMS within 14 days of completion. The Resident Census And Conditions Of Residents report documented 67 residents resided in the facility. Findings: CMS Submission Reports dated 03/16/22 through 10/19/22, documented 403 of of 529 resident assessments were not submitted within 14 days of completion. The facility did not have a policy regarding the submission of resident assessments within 14 days. On 10/20/22 at 9:34 a.m., the MDS coordinator reported they didn't know resident assessments were to be submitted within 14 days of completions. On 10/20/22 at 9:45 a.m., the DON reported they expected resident assessments to be submitted within 14 days of completion. On 10/20/22 at 10:18 a.m., the regional director reported they expected resident assessments to be submitted as per the RAI guidelines.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-10-21 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to staff a registered nurse eight hours a day, seven days a week. The Residents Census And Conditions Of Residents documented 67 residents resided in the facility. Findings: Upon review of the facilities payroll report and the staffing schedule, dated September 2022, the facility had a RN for eight hours a day on 09/05/22, 09/25/22 and 09/26/22 for the month of September 2022. On 10/19/22 at 03:15 p.m., the administrator reported the facility did not have a RN on staff seven days a week for eight hours a day for several days in the month of September. The administrator stated only three days in September were covered by a RN. The administrator reported the facility should have scheduled a RN but none was available.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-21 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure comprehensive assessments were completed in a timely manner on three (#4, 11, and #185) of 37 residents reviewed for comprehensive assessments. The Resident Census And Conditions Of Residents documented 67 residents resided in the facility. Findings: Upon record review, Res #4, 11 and #185 did not have comprehensive assessments completed in a timely manner. A policy and procedure titled Resident Assessment Instrument, dated 12/10, read in parts The Assessment Coordinator is responsible for .timely resident assessments within fourteen (14) days of the resident's admission to the facility . On 10/18/22 at 3:25 p.m., the MDS coordinator reported the assessments should have been done. On 10/18/22 at 3:27 p.m., the DON reported the admission assessments should have been performed. On 10/18/22 3:39 p.m., the regional director reported the admission assessments on Res #4, 11, and #185 were not documented and should have been.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-21 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure quarterly assessments were performed in a timely manner on three (# 12, 145, and #187) of 37 residents reviewed for quarterly assessments. The Resident Census And Conditions Of Residents documented 67 residents resided in the facility. Findings: Upon an electronic health record review, Res #12, 145, and #187 did not have quarterly assessments documented. A policy and procedure, titled Resident Assessment Instrument, dated 12/10, read in parts timely resident assessments and reviews according to the following schedule . At least quarterly . On 10/19/22 at 10:35 a.m., the MDS coordinator reported the quarterly assessments were not done. On 10/19/22 at 10:45 a.m., the regional director reported the quarterly assessments were not done.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-21 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to perform annual skills competencies for nursing staff. The Resident Census And Conditions Of Residents documented 67 residents resided in the facility. Findings: A review of nursing staff competencies were reviewed. CNA #1's last documented competency was dated 09/13/21, LPN #2's last competency was dated 10/29/20, and RN #1's last skills competency was dated 08/28/21. On 10/19/22 at 1:45 p.m., CNA #1 reported the skills competency for this year had not been performed. On 10/20/22 at 8:49 a.m., the DON reported the competencies have not been performed.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-21 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to revise a comprehensive person centered care plan for one (#48) of two residents sampled for care plans. The Resident Census And Conditions Of Residents documented 67 residents resided in the facility. Findings: Res #48 was admitted with diagnoses which included heart failure and hypertension. The Care Planning - Interdisciplinary Team policy, revised 10/10, documented in part .care plans are revised as information about the resident and the resident's condition change. Res #48's quarterly assessment, dated 08/09/22, documented the resident was severely cognitively impaired and required limited assistance with activities of daily living. A physician's order, dated 08/26/22, documented Lasix (a diuretic) 20 mg every morning. A physicians's order, dated 09/26/22, documented discontinue Lasix 20 mg every morning and a new order for Lasix 40 mg every morning and Lasix 20 mg tab at 1:00 p.m. A physician's order, dated 09/28/22, documented Torsemide (a diuretic) 100 mg twice a day. A care plan, revised 10/16/22, did not contain…

    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 · D2022-10-21 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to obtain a physician's order for gastrostomy care on one (#180) of two residents sampled for a gastrostomy tube. The Resident Census And Conditions Of Residents documented two residents received tube feedings. Findings: Res #180 was admitted with diagnoses which included dysphagia and gastrostomy status. An admission assessment, dated 08/25/22, documented Res #180 was severely cognitively impaired, required extensive assistance with activities of daily living, and required tube feeding. Upon review of the electronic health record, Res #180 did not have a physician's order for care of the gastrostomy site. A progress note, dated 10/10/22, documented in part .large amount of dark brown drainage coming from PEG (gastrostomy) site. On 10/17/22 at 10:36 a.m., Res #180 was observed in bed. On 10/17/22 at 02:35 p.m., Res #180 was observed in bed. . On 10/18/22 at 11:20 a.m., LPN #1 reported the care for the gastrostomy site is not ordered and should have been. On 10/19/22 at 12:09 p.m., observed LPN #1 perform care 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.

    Quality of Life and Care 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.

Part of a chain

This home belongs to BGM ESTATE — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.8+0.2 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 1 of 52.1-1.1 vs chain
Quality measures 2 of 52.5-0.5 vs chain
The other 14 homes this chain runs (chain average 1.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
BGM ESTATE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/12/2025
GILBERT GREEN FAMILY INVESTMENTS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/12/2025
CHANCE, GWENDOLYNIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/12/2025
KING, SHAWNAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/12/2025
MCEWING, TORIEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/12/2025
TINDAL, MICHELLEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/12/2025
BELT, MIRANDAIndividualCORPORATE OFFICERsince 12/09/2024
PITTS, JACIIndividualCORPORATE OFFICERsince 12/09/2024
TAYLOR, SANDRAIndividualCORPORATE OFFICERsince 12/27/2020
DRENNAN, KAILEEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/19/2020
GRAY, ERINIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/04/2024
HUTCHINSON, DONNAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/29/2016
JACKSON, BRYONNAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/15/2022
NORVELL, TELISSAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/30/2024
PLUMB, IMRANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2023
ROGERS, RIGGINIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/17/2024
SACKETT, KEITHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/10/2021
SWEETEN, MELANIEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/05/2016
ADVANCED WOUND THERAPYOrganizationADP OF THE SNFsince 11/01/2015
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 01/01/2010
MOBILE WOUND CARE LLCOrganizationADP OF THE SNFsince 09/01/2014
NS GROUP CONSULTING DIVISIONOrganizationADP OF THE SNFsince 10/01/2024
PHARMCAREOK OF DURANT INCOrganizationADP OF THE SNFsince 11/01/2015
STEIN ANCILLARY SERVICES, LLCOrganizationADP OF THE SNFsince 11/01/2015

CMS files one row per role, so the 32 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$6.9M
Net patient revenuemost recent cost report
+23.2%
Operating marginrevenue minus expenses
$480K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 23%Other / private 12%

This home reported $480K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$216per resident / day
operating cost
$6,552per month
≈ monthly operating cost
$281per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.

Typical monthly cost in Oklahoma
$7,026/mo
Nursing home (semi-private)
$7,756/mo
Nursing home (private)
$6,150/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375519. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-12, 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.

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