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Glenhaven Retirement Village

3003 Iowa, Chickasha, OK 73023 · For profit - Corporation · 120 certified beds · (405) 224-0909 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation$14,433 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,433 in federal fines (most recent 2024-09-05)
  • 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
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2222 W Iowa Ave · (405) 224-8111 · Call to confirm hours
Pharmacy
2224 W Iowa Ave · (405) 224-4851 · Call to confirm hours
Grocery
208 S 5th St · (405) 222-1565 · Call to confirm hours
Park
610 W Texas Ave · Typically dawn to dusk
Place of worship
226 S 29th St · (405) 224-1569

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 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 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 rating3★
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 increased21.6%13.6%15.4%worse
Long-stay residents who lose too much weight7.2%3.3%5.4%worse
Long-stay residents with a catheter left in their bladder2.1%1.9%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection17.7%2.8%2.0%worse
Long-stay residents with depressive symptoms2.7%3.4%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury13.0%4.7%3.3%worse
Long-stay residents whose ability to walk worsened17.8%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication32.9%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.1%94.6%95.3%typical
Long-stay residents with pressure ulcers5.2%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control21.4%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table20.8%17.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.7%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine83.0%74.1%79.4%typical
Short-stay residents rehospitalized after admission29.4%27.3%22.6%worse
Short-stay residents with an outpatient ER visit19.7%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.222.311.67better
Long-stay outpatient ER visits per 1,000 resident days2.662.961.80worse

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.

61.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.9%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
63.9%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 63.9% 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 36 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF61.9%CMS range 51.8–70.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 7.1–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.9%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 discharge63.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%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 stay1.8%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 worsened1.8%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 hospitalization6.9%CMS range 3.6–13.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

0.12
RN hours/ resident / day
1.25
LPN hours/ resident / day
3.27
Aide hours/ resident / day
4.64
Total nurse hours/ resident / day
0.14
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 71.2 residents a day — about 59% occupied, or roughly 49 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 4.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.12 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.27 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.11 hrs/resident/day on weekends vs 4.86 on weekdays — 15% thinner on weekends. RN hours go from 0.11 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Inspection trend

1
deficiencies at the latest standard inspection (2024-12-19)
12
at the previous standard inspection (2023-10-12)

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.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-10-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 10/07/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff followed proper procedure for the use of a mechanical lift to prevent accidents. The failure resulted in a fractured hip for Res #1. An undated facility Hydraulic Lift policy documented to check to be sure hooks are secure. A care plan intervention, dated 11/03/23, documented Res #1 required two staff assistance with a Hoyer (full body mechanical lift) for transfers. On 09/08/24, Res #1 had a fall due to the strap on the transfer sling failing to remain attached to the Hoyer lift. The resident was sent to the hospital and diagnosed with a closed hip fracture. Staff were in-serviced on 09/08/24 regarding lift safety and operation, but no ongoing monitoring was completed to ensure staff compliance with safe utilization of mechanical lifts. During interviews with staff conducted on 10/07/24, the staff stated lift sling straps were to be checked to ensure placement prior to lifting a resident.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2022-12-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to notify the physician of an unstageable pressure ulcer, provide appropriate treatment, and provide wound care in a way to help prevent infection for one (#33) of two residents reviewed for pressure ulcers. The facility documented an unstageable ulcer on 11/04/22 and the physician was not notified. On 12/07/22, during an observation of wound care, an additional pressure ulcer was observed. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents resided in the facility who had pressure ulcers. Findings: A Risk Assessment and Pressure Ulcer Policy revised 06/24/08, read in parts, .3. Residents with pressure ulcers will be reassessed on a daily basis to help identify any new impairment of skin integrity .8. Pressure Ulcer Weekly Summary .will be completed and forwarded to DON and Administrator for weekly review for QA purposes .10. All pressure ulcers will be staged according to MDS Assessment definitions. 11. Weekly Pressure ulcer documentation will include site, size (use…

    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 · E2025-01-16 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an effective pest control program. The DON identified 52 residents resided in the facility. Findings: An undated facility Pest policy, read in part, [name of facility withheld] will have monthly pest services to ensure that the facility remains pest free. On 01/16/24 at 8:32 a.m., the DON stated they had reports of spiders, roaches, and mice at least four times a week. On 01/16/25 at 8:46 a.m. an initial tour of the building was conducted. The following observations were made, a. in room C16 there were 14 dead roaches on the floor and roach egg sacks were visible, b. in room C16 there was one live roach located inside the dresser drawer next to the bed with roach eggs and dead baby roaches, and c. dead roaches were located behind the juice machine in the kitchen. On 01/16/25 at 8:47 a.m., the DON was present in room C16. They stated they saw one live roach and all the dead roaches above during the intital tour. On 01/16/25 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-19 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure: a. a diuretic was included on the care plan for one (#23) of five sampled residents reviewed for unnecessary meds; and b. assist rails were included on the care plan for one (#43) of two sampled residents reviewed for restraints. The administrator in training identified 51 residents resided in the facility and 15 residents received diuretics. MDS Coordinator #1 identified three residents had assist rails. Findings: 1. Resident #23 had diagnoses which included hypertensive heart disease with heart failure. A physician order, dated 05/10/24, documented to administer hydrochlorothiazide (diuretic medication) 25 mg in the morning for hypertensive heart disease with heart failure. A physician order, dated 06/22/24, documented to administer furosemide (diuretic medication) 40 mg in the morning for hypertensive heart disease with heart failure. The resident's care plan was reviewed and did not document the use of diuretics. On 12/19/24 at 10:22 a.m., MDS Coordinator #1 stated they did not see diuretics on the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-10-12 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to submit PBJ data to CMS for the third quarter of the fiscal year for 2023. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings The PBJ Staffing Data Report documented the facility failed to submit data for the third quarter of 2023 (April 1 - June 30). On 10/10/23 at 9:43 a.m., the BOM was asked how often the facility submitted staffing data to CMS. They stated quarterly. They were asked if they had submitted data for the third quarter of 2023. 10/10/23 at 11:18 a.m., the BOM stated they did not submit the data for the quarter and should have.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-12 · 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 — 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 comprehensive assessment were accurate and/or completed timely for two (#6 and #44) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: 1. Res #6 was admitted to the facility on [DATE] with diagnoses which included depression, insomnia, heart failure, and chronic kidney disease. An admission assessment, dated 05/03/23, documented on 06/15/23 the RN assessment coordinator signed the assessment as completed. On 10/11/23 at 2:49 p.m., MDS Coordinator #1 was asked about the type of assessment they had completed for the resident. They stated they would have to look. They stated the assessment should have been an annual assessment. They stated they marked the assessment incorrectly. MDS Coordinator #1 was made aware the assessment was completed on 06/15/23 when the ARD was 05/03/23. She stated they knew it was not completed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-12 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 quarterly assessments were completed once every three months and/or no later than 14 days after the ARD for two (#6 and #36) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: 1. Res #6 had diagnoses which included depression, insomnia, heart failure, and chronic kidney disease. A quarterly resident assessment, dated 07/28/23, documented on 09/09/23 the RN assessment coordinator signed the assessment as completed. On 10/11/23 at 2:49 p.m., MDS Coordinator #1 was made aware the resident had a quarterly assessment completed on 09/09/23 when the ARD was 07/28/23. They stated they knew the assessment had not been completed within 14 days of the ARD. 2. Res #36 had diagnoses which included abdominal aortic aneurysm without rupture, COPD, disorder of kidney and ureter, cerebral infarction, pure hypercholesterolemia, unspecified osteoarthritis, generalized anxiety disorder, chronic pain…

    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 · E2023-10-12 · tag F0656 — failed to write and follow a full care plan — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to fully develop comprehensive care plans for four (#6, 8, 44, and #47) of 13 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: 1. Res #6 had diagnoses which included depression, insomnia, heart failure, and chronic kidney disease. A comprehensive resident assessment, dated 05/05/23, documented activities was a care planning decision on the CAA summary. There was no documentation activities was developed on the care plan. On 10/11/23 at 4:40 p.m., MDS Coordinator #1 was shown the resident's assessment where activities was a care planning decision. They were asked if the resident's care plan was developed to include activities. They reviewed the resident's care plan and stated it was not on the care plan and should have been. 2. Res #44 had diagnoses which included a pressure ulcer to the sacrum. An admission assessment, dated…

    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 · Ecited before2023-10-12 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to review and/or revise the care plan related to: a. a decrease in mobility for one (#3) of 13 residents whose care plans were reviewed, and b. fall prevention interventions for one (#28) of 13 residents who were reviewed for accidents. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: A Fall Focus Program policy, revised 04/23/07, read in parts, .Incident of fall: Consider and evaluate factors regarding fall and develop care plan using appropriate interventions .Review the fall at next safety committee meeting and gain input for interdisciplinary team members for other possible interventions to prevent falls. Make sure to update and revise plan of care as indicated .Schedule care plan meetings as indicated for review and revision . 1. Res #3 had diagnoses which included intellectual disabilities, convulsions, and thyrotoxicosis. An annual assessment, dated 06/20/23, documented the resident was severely cognitively impaired 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-12 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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 provide nail care for one (#34) of two sampled residents reviewed for activities of daily living. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: Res #44 had diagnoses which included ventricular tachycardia, hypokalemia, chronic ischemic heart disease, unspecified diastolic congestive heart failure, hypotension, GERD, muscle weakness, and acute respiratory failure. A quarterly resident assessment, dated 09/08/23, documented their cognition was intact and they required extensive assistance with personal hygiene. On 10/09/23 at 11:58 a.m., the resident was observed in their bed with their left foot exposed. Their toenails were excessively long. The resident was asked when was the last time their toenails had been trimmed. They stated they did not know. They stated their toenails were extremely long and it caused pain to their left foot. On 10/10/23 at 1:04 p.m., CNA #2 was asked how often nail care was provided. They stated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-12 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to turn and reposition a resident with limited range of motion (ROM) in order to increase ROM and/or prevent further decline for one (#1) of three residents reviewed for mobility. The Resident Census and Conditions of Residents report, documented 44 residents who required assistance with mobility. Findings: A Nursing Assistant Duties general guideline, undated, documented to turn and reposition all bed and chair residents every two hours and all wheelchair residents are to be checked frequently and taken to the bathroom at least every two hours as requested or per individual schedule. Res #1 was admitted with diagnoses which included restless leg syndrome, muscle spasms, and colon cancer. A care plan, dated 01/31/23, documented the resident required total assistance with most ADLs with an intervention of assistance and/or reminders to turn and reposition every two hours. A quarterly assessment, dated 07/11/23, documented the resident was cognitively intact, required extensive one person assistance with mobility,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent falls for one (#39) of three sampled residents reviewed for accidents. The facility failed to consistently implement interventions to prevent recurrence and evaluate interventions for effectiveness for a resident who had frequent falls. The Resident Census and Conditions of Resident report documented 46 residents resided in the facility. Findings: A Fall Focus Program policy, revised 04/23/07, read in parts, .Fall risk factor evaluation: Review any health problems or conditions that could contribute to a fall .Review the medications that could contribute to a fall .Review environmental hazards such as poor lighting, carpet, poorly arrange furniture .Review previous falls to determine patterns .Incident of fall: Consider and evaluate factors regarding fall and develop care plan using appropriate interventions .Review the fall at next safety committee meeting and gain input for interdisciplinary team members for other possible…

    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
Show the remaining 17 citations
  • Potential for harm · E2023-10-12 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to: a. attempt appropriate alternatives prior to installing bed or side rails; b. perform an entrapment risk assessment; c. review the risks or benefits with the resident and/or their representative; d. obtain an informed consent; and e. develop a care plan for side rail use for one (#39) of three sampled residents reviewed for accident hazards. The DON identified 16 residents whose beds were equipped with a bed rail of any type. Findings: A Bed Rail policy, undated, read in parts, .A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) bed maintenance as needed and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment .No matter the purpose for use, bed rails and other bed accessories, although prescribed to improve functional independence with bed mobility and transfers, can increase resident safety risk. Thus, weighting the risks and benefits of devices (including bed rails) is integral to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-12 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#39) of three residents reviewed for accident hazards. The DON identified 16 residents whose beds were equipped with a bed rail of any type. Findings: A Bed Rail policy, undated, read in parts, .A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) bed maintenance as needed and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment .No matter the purpose for use, bed rails and other bed accessories, although prescribed to improve functional independence with bed mobility and transfers, can increase resident safety risk. Thus, weighting the risks and benefits of devices (including bed rails) is integral to achieving positive resident outcomes . Res #39 was admitted with diagnoses which included diabetes mellitus, overactive bladder,…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure physician orders were obtained for code status for two (#26 and #1) of 13 sampled residents reviewed for code status. The DON identified 23 residents who were DNR's. Findings: 1. Res #26 was had diagnoses which included chronic kidney disease, HTN, atrial fibrillation, and pain. A DNR consent form, dated 04/17/23, was located in the resident's medical chart. There was no physician order for the resident's code status. On 10/11/23 at 8:53 a.m., the DON was asked what was the resident's code status. They stated they were a DNR. They were asked if there was a physician order for the resident's code status. They stated there was not. 2. Res #1 had diagnoses which included asthma, restless leg syndrome, and muscle spasms. A DNR consent form, dated 08/16/06, was located in the resident's medical chart. There was no physician order for the resident's code status. On 10/12/23 at 11:40 a.m., the DON stated Res #1 had a documented DNR consent form but there was no physician order for the resident's code status.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a significant change in status MDS was completed timely by the 14th calendar day after the determination the significant changes has occurred for one (#26) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, docuented 46 residents resided in the facility. Findings: Res #26 had diagnoses which include chronic kidney disease. A significant change assessment, dated 08/08/23, documented on 09/12/23 the RN assessment coordinator signed the assessment as completed. On 10/10/23 at 4:27 p.m., MDS Coordinator #1 was asked the reason a significant change assessment had been completed. They stated the resident started on dialysis. They were made aware the assessment was completed on 09/12/23 when the ARD was 08/08/23. They stated the assessment should have been completed within 14 days of the ARD.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-08 · tag F0580 — failed to tell family and doctor about changes — pattern
    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, observation, and interview, the facility failed to notify the physician of a new pressure ulcer for one (#33) of two residents reviewed for pressure ulcers. The Resident Census and Condition of Residents report, dated 12/06/22, documented two residents had pressure ulcers in the facility. Findings: Res #33 had diagnoses which included osteomyelitis, depressive disorder, and Alzheimer's disease. A quarterly assessment, dated 09/10/22, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident did not have any pressure ulcers but did have MASD. A care plan, last revised 09/16/22, documented no skin issues on the care plan. A Wound Care Status Report dated 11/04/22, documented the resident had a 1 x 1cm stage I pressure ulcer with epithelial and slough. The report documented treatment of betadine and Optifoam dressing. A dietary note, dated 12/02/22, documented a pressure ulcer was present. On 12/05/22 at 5:25 a.m., Res #33 reported he had a wound to his bottom. He stated the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-08 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 assessments accurately reflected the residents status for three (#10, 29, and #32) of 14 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility. Findings: 1. A physician order, dated 12/11/21, documented Res #10 was to receive methenamine hippurate (Hiprex) (anti-infective medication) 1gm tablet for UTI. A quarterly assessment, dated 03/07/22, documented the resident received an antibiotic for seven days during the last seven days or since admission/entry if less than seven days. The February and March 2022 MARs were reviewed and documented Hiprex was received. A quarterly assessment, dated 05/31/22, documented the resident received an antibiotic for seven days during the last seven days or since admission/entry if less than seven days. The May 2022 MARs were reviewed. It documented Hiprex was received. A quarterly assessment, dated 08/23/22, documented the resident received an antibiotic for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-08 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for one (#1) of one resident who was reviewed for ADLs. The Resident Census and Condition of Residents report, dated 12/06/22, documented 43 residents resided in the facility. Findings: Res #1 had diagnoses which included COPD, chronic pain, and traumatic brain injury. A quarterly assessment, dated 11/01/22, documented the resident was intact with cognition and required total assistance with bathing. A care plan, last reviewed 11/07/22, documented the resident required total to extensive assistance meeting ADL needs. Res #1 required staff to assist for showers. The resident's bathing schedule was documented as Monday, Wednesday, and Friday on the 7:00 a.m. to 3:00 p.m. shift. The resident was scheduled for 13 baths for November 2022. The POC bathing history report for November 2022 documented the resident received six baths out of 13 for the month. On 12/05/22 at 10:30 a.m., Res #1 stated he was supposed to get a bath every day and did not get them as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to assess for risks associated with smoking for one (#42) of one resident sampled for smoking. RN #1 identified three residents who smoked. Findings: Resident #42 admitted to the facility on [DATE] with diagnoses including dementia, depression, and diabetes. An admission MDS, dated [DATE], documented the resident was cognitively intact, was independent without staff assistance for most ADL's, and did not use tobacco. On 12/05/22 at 9:21 a.m., Res #42 was observed on the front porch of the facility with a tobacco pipe and lighter resting on his rolling walker. He stated he had not been at the facility very long. On 12/05/21 at 9:35 a.m., RN #1 was asked if Res #42 was on the facility smoking list. She stated she was unaware the resident was a smoker. On 12/05/22 at 9:40 a.m., the administrator stated when the resident admitted to the facility Res #42 was not smoking. She stated the resident's daughter had been contacted and stated Res #42 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-08 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation and interview, the facility failed to provide physician ordered weekly weights for one (#29) of two residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents with unplanned weight loss or gain. The RN provided documentation of 15 residents who were to receive weekly weights. Findings: Res #29 had diagnoses which included diabetes mellitus, dysphagia, and COPD. A physician order, dated 10/21/20, documented to weigh weekly on Thursday day shift. A quarterly assessment, dated 08/15/22, documented the resident was severely impaired with cognition, required total assistance with ADLs, and had no significant weight loss or gain, and weighed 142 lbs. A care plan, last revised 11/09/22, documented to weigh Res #29 weekly, reweigh if five pounds gain or loss, and notify the physician of continued weight loss or gain. An annual assessment, dated 11/07/22, documented the resident was severely impaired with cognition, required total assistance with ADLs, and had no significant weight…

    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 · E2022-12-08 · 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 ensure nursing staff completed required competency demonstrations annually. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: On 12/07/22 at 5:00 p.m., competency documentation was requested. On 12/08/22 at 8:25 a.m., RN #1 stated she did not have documentation of competencies because the facility did not perform them in 2021 and had not yet done them in 2022.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-08 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a registered nurse served in the facility for at least eight consecutive hours a day, seven days a week. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: A Monthly Shift Staffing Report for October 2022 documented: On 10/07/22 the total RN hours documented was 7.2. On 10/08/22 the total RN hours documented was 6.0. On 10/09/22 the total RN hours documented was 6.2. On 10/14/22 the total RN hours documented was 6.7. On 10/28/22 the total RN hours documented was 7.5. A Monthly Shift Staffing Report for November 2022 documented: On 11/04/22 the total RN hours documented was 6.7. On 11/05/22 the total RN hours documented was 6.0. On 12/08/22 at 10:34 a.m., the administrator stated there was no agency RN employed on the days identified as having less than eight hours of RN coverage. She stated she was aware of a couple of times the weekend RN had to leave early, and that she would talk to her to ensure that she stayed for eight hours or had another RN relieve…

    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 · E2022-12-08 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to obtain labs as ordered by the physician for one (#6) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility. Findings: Res #6 had diagnoses which included heart disease, chronic kidney disease, gastrointestinal hemorrhage, and hypokalemia. A physician order, dated 10/10/21, documented CBC, Chem-14 (CMP), and UA with C&S if indicated monthly on the first Wednesday every six months starting on 03/02/22. There was no documentation a UA with C&S if indicated was obtained in March 2022. There was no documentation a CBC, CHEM 14, and UA with C&S if indicated was obtained in September 2022. On 12/07/22 at 1:58 p.m., RN #1 was asked to locate an UA with C&S if indicated obtained in March 2022 and a CBC, CHEM 14, and UA with C&S if indicated in September 2022. On 12/07/22 at 2:34 p.m., RN #1 stated she could not locate the labs.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to perform proper hygiene during wound care for one (#33) of one observed for wound care and perform proper hand hygiene when delivering meals to residents. The Resident Census and Condition of Residents report, dated 12/06/22, documented 43 residents resided in the facility. Findings: 1. On 12/05/22 at 6:36 a.m., the DM was observed to pass a meal to a resident and lean on the table with her hands. The DM did not perform hand hygiene before passing another meal to another resident in the dining room. On 12/05/22 at 7:05 a.m., the breakfast cart came out of the kitchen to B hall and nursing staff started passing meals. On 12/05/22 at 7:06 a.m., CNA #6 was observed to touch her eye glasses and deliver a meal to a resident's room, CNA #6 pulled the privacy curtain and assisted the resident to sit up to eat. CNA #6 then washed her hands. On 12/05/22 at 7:07 a.m., CNA #7 was observed to touch her name badge and then delivered a meal to a resident without using…

    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 · E2022-12-08 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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: a. offer the influenza vaccination to each resident annually for two (#27 and #38) and b. administer the pneumococcal immunization for two (#2 and #6) of five sampled residents reviewed for influenza and pneumococcal immunizations. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility. Findings: An undated Pneumonia Vaccination Program policy, read in part, .policy is to provide all residents who do not have an allergy to the vaccine, the pneumonia vaccination . The Influenza Vaccination Program policy, revised April 2007, read in parts, .policy is to provide all residents .who do not have allergy to the vaccine, the influenza vaccination yearly . 1. A pneumonia vaccination consent/declination form, dated 09/30/21, documented consent for Res #2 to receive the pneumococcal immunization. There was no documentation the pneumococcal immunization was administered. On 12/08/22 at 2:24 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · tag F0638 — isolated
    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 a quarterly assessment was completed no later than 14 days after the ARD for one (#10) of 14 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility. Findings: A quarterly assessment, dated 11/15/22, documented the status of the assessment for Res #10 was incomplete. On 12/08/22 at 11:15 a.m., the MDS coordinator was asked when a quarterly assessment was considered to be timely. She stated she had 92 days from the previous assessment. She was made aware the status of Res #10's 11/15/22 assessment was incomplete. She stated she would have to look. She stated section D needed to be completed. She stated it was an oversight.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0640 — isolated
    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 MDS assessments to CMS within seven days of completion for one (#19) of one resident sampled for assessment transmission. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: A quarterly MDS assessment, dated 10/03/22, for Res #19 was documented as transmitted to CMS on 12/07/22. On 12/08/22 at 8:08 a.m., the MDS coordinator stated she did not have access to the transmittal software and the business office manager transmits all assessments. On 12/08/22 at 8:28 a.m., the BOM stated he transmitted MDS assessments once per month and confirmed the assessment for Res #19 was not submitted timely per regulation.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · 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, observation, and interview the facility failed to revise a care plan related to pressure ulcers for one (#33) of two residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents have pressure ulcers. Findings: Res #33 had diagnoses which included osteomyelitis, depressive disorder, and Alzheimer's disease. A quarterly assessment, dated 09/10/22, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident did not have any pressure ulcers but did have MASD. A care plan, last revised 09/16/22, documented no skin issues on the care plan. A Wound Care Status Report dated 11/04/22, documented the resident had a 1 x 1cm stage I pressure ulcer with epithelial and slough. The report documented treatment of betadine and Optifoam dressing. A dietary note, dated 12/02/22, documented a pressure ulcer was present. On 12/05/22 at 5:25 a.m., Res #33 reported he had a wound to his bottom. He stated the facility was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,433 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $14,433 — penalty dated 2024-09-05
  • Medicare payment denial — starting 2024-11-12 for 3 days

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

Who owns this facility

Owner / managerTypeRoleShareSince
HAMILTON, GLENDAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 07/09/2004
LANCE, BILLYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 07/09/2004
MASON, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 05/01/2005
MASON, PATRICKIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 07/09/2004
TRETT, JENNYIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/09/2004

CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

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

$3.4M
Net patient revenuemost recent cost report
-41.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 62%Medicare 12%Other / private 25%

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

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$296per resident / day
operating cost
$8,989per month
≈ monthly operating cost
$210per 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 375359. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-19, 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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