Shanoan Springs Nursing and Rehabilitation
2500 South 12th Street, Chickasha, OK 73018 · For profit - Limited Liability company · 82 certified beds · (405) 224-1397 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2026-03-25)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (74%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 24.8% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.9% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.1% | 2.8% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 2.9% | 3.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 4.7% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 24.5% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 36.6% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.4% | 17.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.0% | 17.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.8% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 19.4% | 27.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.7% | 16.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.94 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.40 | 2.96 | 1.80 | worse |
‡ 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.
45.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.4% 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 21 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 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 45.9%CMS range 35.0–59.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 7.8–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 52.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 11.2%CMS range 6.7–17.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.38 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 82 beds and averages 51.6 residents a day — about 63% occupied, or roughly 30 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 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.68 hrs/resident/day on weekends vs 4.26 on weekdays — 14% thinner on weekends. RN hours go from 0.26 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 74% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-03-25 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
On 03/24/26, a past noncompliance Immediate Jeopardy (IJ) situation was determined to have existed related to the facility's failure to ensure Res #3 received a mechanically soft diet without bread per physician order. Res #3 was provided a grilled cheese sandwich and side salad for an evening meal, which resulted in a choking episode requiring emergency services.On 03/24/26 at 3:15 p.m., the OSDH was notified and verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents received physician ordered therapeutic diets.On 03/24/26 at 3:28 p.m., the administrator was notified of the immediate jeopardy situation.Based on observation, record review, and interview, the facility failed to ensure a resident received a physician ordered mechanical soft diet without bread for 1 (#3) of 3 sampled residents reviewed for therapeutic diets.The dietary manager identified 22 residents received therapeutic diets.Findings:On 03/23/26 at 11:35 a.m., dietary staff were observed preparing residents' lunch trays. Nursing staff were observed verifying the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-30 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 advanced directives were sent with a resident during a transfer for 1 (#205) of 1 sampled residents reviewed for appropriate documentation sent to receiving provider. The administrator identified 49 residents resided in the facility. Findings: A policy Transfer or Discharge, Information for Receiving Provider, dated 2001, read in part, Should a resident be transferred to another facility or discharged to the care of another provider, the following information is communicated to the receiving facility or provider .Advance directive information. On 02/01/25, a nurses note showed Resident #205 was transferred out to a hospital due to labored breathing and coughing up thick green phlegm. On 02/06/25, a nurses note showed hospital staff called Shanoan Springs to request a copy of the medications that were in effect at the time of the transfer to the ER on [DATE]. On 02/10/25, a nurses note showed hospital staff called Shanoan Springs to request a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure proper personal protective equipment was used for 1 (#42) of 4 sampled residents reviewed for enhanced barrier precautions. The administrator identified 19 residents resided in the facility required enhanced barrier precautions. Findings: On 05/29/25 at 9:10 a.m., LPN #1 was observed to enter Resident #42's room to administer medications via enteral tube. LPN #1 did not don PPE prior to administering the medications via enteral tube. An undated policy Enhanced Barrier Precautions, read in part, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce the transmission of multidrug-resistant organisms .Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities. A policy Administering Medications Through an Enteral Tube, revised 11/2008, read in part, The purpose of this procedure is to provide guideline for the safe administration of medications through an enteral tube .The following equipment and supplies will be necessary when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. The facility identified 48 residents who received their meals from the kitchen. Findings: 1. On 04/15/24 at at 8:21 a.m., an initial tour of the kitchen was conducted. The following observations were made. [NAME] # 1 was observed to take the trash out of the trash can and the trash was taken outside. [NAME] #1 was observed to return to the kitchen and did not wash their hands. [NAME] #1 placed a lid on the chicken, which was on the prep counter in marinade, and then placed the container in the refrigerator. [NAME] #1 was then observed to cover a bowl of cream cheese with plastic wrap, and then placed individual containers of butter into a bowl. Hand washing was not observed during this observation. On 04/15/24 at 8:30 a.m., the following was observed in the refrigerator: Opened containers of Thick and Easy drinks were not dated with an open date An opened bottle of water, with some water missing, in the refrigerator and 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.
- Potential for harm · E2024-04-18 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents were offered to formulate an advance directive, or implemented the choice to formulate an advanced directive, for three (#8, 20, and #42) and posted the correct information regarding code status for one (#2) for 24 residents reviewed for advance directives. The administrator identified 50 residents who resided in the facility. Findings: 1. Res #8 had diagnoses which included atrial fibrillation, COPD, and chronic pain. A quarterly assessment, dated 03/27/24, documented the resident was moderately impaired with cognition and required partial to moderate assistance with most ADLs. On 04/15/24 at 10:55 a.m., a green name tag, indicating full code status, was observed by the resident room. 04/16/24 at 9:00 a.m., the residents advance directive acknowledgment form was provided. The undated form documented the resident had an advance directive. The AD acknowledgment form was signed by the resident. The resident did not have an AD in the EHR or in the hard chart. On 04/16/24 at 9:20 a.m., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-18 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 ensure food was served at an appetizing temperature. The facility identified 48 residents who received their meals from the kitchen. Findings: 1. On 04/17/24 at 11:00 a.m., the menu was observed and documented the noon meal was to have been french onion pork chops, pork gravy, white cheddar mac and cheese, green peas, wheat dinner roll, margarine, apple [NAME], milk, and coffee. On 04/17/24 at 11:10 a.m., [NAME] #1 was observed to obtain the temperature of the pork chops when they were removed form the oven. The temperature at that time was 184 degrees F. The pork chops were place in a deep pan and then placed on the steam table. The other food items were not observed to be temped before placing on the steam table. On 04/17/24 at 12:01 p.m., the meal service started. The steam table was not temped before service started. On 04/17/24 at 12:20 p.m., the DM stated they should have temped the food on the steam table before serving the meal. The DM 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.
- Potential for harm · Ecited before2024-04-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure: a. wound care was provided in a sanitary manner for one (#20) of four residents observed for wound care, b. residents' catheters were not dragging on the floor for two (#8 and #26) of four sampled resident who had catheters, and c. a water management program was implemented to prevent the growth of Legionella and other opportunistic waterborne pathogens in the buildings water system. The facility identified a census of 50 residents who resided in the facility. Findings: 1. Res #8 had diagnoses which included diabetes mellitus, personal history of urinary tract infections, and neuromuscular dysfunction of the bladder. A care plan, last revised 10/18/23 documented the resident has a suprapubic catheter for neurogenic bladder. The care plan documented to keep the catheter bag below the bladder level and monitor for sign and symptoms of UTI. The care plan documented the resident was on enhanced precautions required due to Res #8 was at an increased risk for infection and MDRO related to indwelling medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 ensure an allegation of abuse was reported within two hours of the reported incident for one (#8) of three residents sampled for abuse. The administrator identified 50 residents residing in the facility. Findings: A facility policy titled Reporting Abuse to Facility Management, dated April 2012, read in part, .The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or paged and informed of such incident . Res #8 had diagnoses which included atrial fibrillation, COPD, and chronic pain. A quarterly assessment, dated 03/27/24, documented the resident was moderately impaired with cognition and required partial to moderate assistance with most ADLs. On 04/15/24 at 2:40 p.m., Res #8 stated stated yesterday a nurse said the F word at them and it hurt their feelings. The resident stated they told other staff member but did not know their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#8 and #20) of 13 sampled residents whose resident assessments were reviewed. The administrator identified 50 residents who resided in the facility. Findings: 1. Res #8 had diagnoses which included anxiety disorder, major depressive disorder, bipolar disorder, and schizophrenia. A quarterly assessment, dated 03/27/24, documented the resident was moderately impaired with cognition. The assessment documented the resident received an antipsychotic, antianxiety, and an antidepressant medication. The assessment documented a GDR had been attempted on 10/06/23. On 04/18/24 at 10:57 a.m., the MDS coordinator stated they were brand new to the MDS position as of September of 2023. The MDS coordinator stated they found the date on a psychiatric consultation progress note for September and it had been signed and dated on 10/06/23. On 04/18/24 at 11:36 a.m., the DON stated on 09/18/24 the psychiatrist came to the facility and made changes in the resident's medication. They 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.
- Potential for harm · D2024-04-18 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#2) of one sampled residents reviewed for PASRR. Findings: A PASRR level I was provided by another facility that was transferring services to this facility, dated 06/30/10, documented Res #2 had diagnoses including multiple sclerosis, neurogenic bladder, paraplegia, sebaceous cysts, and [NAME]-[NAME] syndrome. Res #2 was admitted on [DATE] after being transferred from another facility, and had diagnoses which included multiple sclerosis, [NAME]-[NAME] syndrome, neurogenic bladder, paraplegia, sebaceous cysts, dementia in other diseases with agitation, delusional disorder, cognitive communication deficit, and dementia with behavioral disturbances. A significant change assessment dated [DATE] documented the resident was severely impaired with cognition and diagnosed with psychotic disorder. A care plan revised on 08/14/23, documented the resident had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure nutritional supplements were given to one (#49) of two residents reviewed for weight loss. The DON identified 50 residents residing in the facility. Findings: Resident #49 was admitted with diagnoses including diffuse traumatic brain injury and hemorrhage with loss of consciousness of unspecified duration and need for assistance with personal care. The resident was also admitted with a gastric tube. A physician's order on 03/28/24 documented enteral feed TwoCal HN four times a day via gastric tube. On 04/02/24 a dietitian recommended the resident be given TwoCal HN five times a day via gastric tube. There was no documentation of the physician being notified of this dietitian recommendation. On 04/17/24 at 11:01 a.m., the ADON stated the dietitian would examine each resident remotely and send the recommendations to their email. They also stated there are times when we miss those recommendation related to not looking at our emails. On 04/17/24 at 11:07 a.m., the DON stated they did not see the note from the dietitian.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2024-04-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to follow physician's orders for oxygen tubing care maintenance for one (#33) of one resident sampled for oxygen therapy. The administrator reported 50 residents resided in the facility. Findings: Resident #33 was admitted with diagnoses of chronic obstructive pulmonary disease, respiratory failure, and dependency of supplemental oxygen. A physician's order, dated 01/22/24, documented to change the oxygen tubing on the 5th and 20th of each month on the night shift. A quarterly assessment, dated 03/25/24, documented the resident utilized oxygen. On 04/15/24 at 10:59 a.m., an observation was made with the resident wearing oxygen via nasal canula and the tubing documented a date of 03/06/24. On 04/16/24 at 8:10 a.m., an observation was made with the resident wearing oxygen via nasal canula and the tubing documented a date of 03/06/24. On 04/17/24 at 11:50 a.m., an observation was made with the resident wearing oxygen via nasal canula and the tubing documented a date of 03/06/24. The treatment administration record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the use of side rails was appropriate for one (#49) of one sampled residents who were reviewed for side rails. The administrator identified 21 residents residing in the facility utilized bed rails of any type. Resident #49 was admitted with diagnoses including diffuse traumatic brain injury and hemorrhage with loss of consciousness of unspecified duration and need for assistance with personal care. An admission assessment, dated 03/25/24, documented the resident was severely impaired with cognition and was totally dependent with ADLs. A physician order, dated 03/25/24 at 7:00 a.m., documented to monitor placement and function of low air loss mattress every shift for placement and function. On 04/15/24 at 10:55 a.m., an observation was made of Res #49 lying on an air mattress with bed rails on both sides of the bed. The resident's EHR did not document a physician order for bed rails. The resident's care plan did not document a care plan for the use of side rails. The resident's records contained a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to: a. ensure a consultant pharmacist reviewed the medication of each resident in the facility monthly for two (#8 and #42) of five sampled residents reviewed for unnecessary medications. b. ensure the physician responded in the time frame documented by the facility policy to the MRR for one (#42) of five sampled residents reviewed for unnecessary medications, and c. ensure the physician responded to the MRR request for two (#8 and #42 of five sampled residents reviewed for unnecessary medications. The administrator identified 50 residents who resided in the facility. Findings: A facility policy, dated 2024, titled Drug Regimen Review, read in part .The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .If the facility has not received any communication from the physician regarding the Drug Regimen Review (DRR) within 30 business days, the facility staff will call the physician .The physician provides a written response of the report to the facility within one month after the report 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.
- Potential for harm · Dcited before2024-04-18 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure menus were followed. The facility identified one resident who received a puree meal, one resident who received finger foods, for a total of 48 residents who received their meals from the kitchen. Findings: On 04/17/24 at 11:00 a.m., the menu was observed and documented the noon meal was to have been french onion pork chops, pork gravy, white cheddar mac and cheese, green peas, wheat dinner roll, margarine, apple [NAME], milk, and coffee. On 04/17/24 at 11:54 a.m., cook #1 was observed to have pureed the meal for the resident who required pureed meals and had not included a roll. On 04/17/24 at 12:01 p.m., during the meal service, four meals were observed to be served without rolls. On 04/17/24 at 12:15 p.m., Res # 25 was observed to have been served butter noodles, the white cheddar mac and cheese and green beans. The resident was not served a pork chop with their noon meal. DA #3 stated the resident received finger foods. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure the garbage from the kitchen was disposed of properly. The facility identified 48 residents who received services from the kitchen. Findings: On 04/15/24 at 8:25 a.m., [NAME] #1 was observed to take the trash out of the garbage can in the kitchen and placed the trash sack in a shopping cart which was located outside of the kitchen by the outside storage building. On 04/15/24 at 9:03 a.m., the DM stated the staff had been taking the trash out to the shopping cart and then they would take the trash down to the trash receptacle. The DM stated they should have immediately taken the trash to the trash receptacle bin at the street and not left the trash in the shopping cart. On 04/17/24 at 11 :25 a.m., a small bag of trash was observed unattended in the shopping cart outside by the storage room.
- Potential for harm · E2024-04-18 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse and neglect for two (#35 and #40) of three residents sampled for abuse. a. On 10/19/23, an initial Incident Report documented CNA #1 did place their hand over the mouth and nose of the Res #35 on 3 different occasions during a shower. It was also reported that CNA #1 told the resident to shut up. All those involved were suspended until the investigation was complete. CNA #1 was separated from employment immediately and CNA #2 was educated one-on-one related to reporting abuse immediately. On 10/24/23 an in-service and training was initiated by management to all staff members at the facility on abuse, neglect, dementia, reporting abuse, rights of residents, and bathing residents. On 10/26/23 management completed the in-service and training for all staff members at the facility. The facility was in past non compliance after completing a QAPI meeting, dated 03/20/24, which discussed the outcome of the State Reportable Incident(s) interventions. b. On 02/11/24 at 11:15 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the services to maintain grooming and personal hygiene. The Long-Term Care Facility Application for Medicare and Medicaid form documented 50 residents resided in the facility. Findings: Res #102 was admitted on [DATE] and had diagnoses which included laceration without foreign body of right eyelid and periocular area, need for assistance with personal care, and intellectual disabilities. A care plan, dated 02/06/24, documented the resident required extensive assistance of one staff member with showering or bathing. A medicare five day assessment, dated 02/08/24, documented the resident required substantial to maximal assistance with bathing. The resident was discharged on 02/12/24. On 04/17/24 at 1:33 p.m., the ADON brought bathing sheets and after review confirmed that documentation verified the resident was showered twice while a resident, on 02/09/24 and 02/10/24 out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the laundry room was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 56 residents resided in the facility. Findings: On 03/06/23 at 12:08 p.m., a tour of the laundry room was conducted. The following observations were made: a. Light covers were missing off of the ceiling lights and ceiling lights were burned out and/or not working. b. There was an accumulation of lint on the ceiling light covers, ceiling fan, and the laundry equipment. c. There was an accumulation of bugs inside of the ceiling light covers. d. The ceiling was not finished near the entry/exit doors. The sheet rock was not sealed. e. There was an accumulation of white residue and lint on the floor. f. There were gaps and daylight was visible under the entry/exit doors. On 03/06/23 at 12:20 p.m., the laundry supervisor was asked how staff ensured the laundry room was kept clean and maintained in good repair. She stated they had a cleaning schedule. She stated they cleaned and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the kitchen was kept clean, maintained in good repair, and chemicals were properly labeled. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 56 residents resided in the facility. Findings: On 03/02/23 at 9:35 a.m., a tour of the kitchen was conducted. The following observations were made: a. There was an accumulation of black residue, trash, and food on the floor. b. There was an accumulation of black and brown residue on the wall behind the dish machine. c. There was water leaking from the hot water knob on the two compartment sink. d. The ceiling lights were not covered. The light cover was missing near the steam table. e. The baseboard was missing off of the wall in the dish wash area. f. There was an accumulation of food, grease, and black residue on the dish machine, drain boards, sinks, steam table, dish racks, food preparation table, stove, and outside area of food storage containers. g. Spray bottles of a clear and yellow liquid were stored on top of the dish machine and were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 don gloves prior to the administration of subcutaneous insulin injections. The Resident Census and Conditions of Resident report documented 10 residents received injections in the facility. Findings: A Subcutaneous Injections policy, revised March 2011, documented to perform hand antisepsis and put on gloves prior to a subcutaneous injection. On 03/03/23 at 8:34 a.m., RN #1 was observed to have administered a subcutaneous insulin injection to Res #50. RN #1 performed hand antisepsis but did not don gloves prior to the administration of the subcutaneous injection. On 03/03/23 at 8:45 a.m., RN #1 was observed to have administered a subcutaneous insulin injection to Res #32. RN #1 performed hand antisepsis but did not don gloves prior to the administration of the subcutaneous injection. On 03/03/23 at 8:47 a.m., RN #1 was asked if gloves should be worn during the administration of a subcutaneous insulin injection. RN #1 stated she did not believe there was a need to wear gloves because the residents 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.
- Potential for harm · D2023-03-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure resident care plans were reviewed and revised after falls for two (#32 and #39) of two residents reviewed for falls. The Resident Census and Conditions of Resident report documented 56 residents resided in the facility. Findings: 1. Res #32 had diagnoses which included cerebral infarction, muscle weakness, and dysarthria. A care plan, dated 12/26/22, documented Res #32 was a fall risk related to deconditioning and gait and balance problems. The care plan documented a goal that the resident's risk for falls will be decreased through nursing and therapy interventions. An annual assessment, dated 12/26/22, documented the resident was moderately cognitively impaired, did not ambulate, required extensive two-person assistance with transfer, and had one fall with no injury. An incident report, dated 01/22/23, documented the following: Res #32 was found on the floor in the bathroom. The resident stated the fall occurred while trying to get back into the wheelchair after getting off the toilet. The resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-06 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The Resident Census and Conditions of Residents form documented 56 residents resided in the facility. Findings: On 03/02/23 at 11:39 a.m., the south hall nurse staffing information was not posted. On 3/03/23 at 8:03 a.m., the south hall nurse staffing information was not posted. On 03/06/23 at 8:25 a.m., the north hall nurse staffing information was not posted. On 03/06/23 at 2:00 p.m., the corporate nurse reported the nurse staffing information should have been posted daily.
- Potential for harm · D2023-03-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to limit PRN orders for psychoactive medications to 14 days for one (#12) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 14 residents received antianxiety medications. Findings: Resident #12 had diagnoses which included anxiety. A current physician order, dated 12/09/21, documented lorazepam concentrate 1 mg/0.5 ml apply to wrist topically every six hours as needed. The December 2022 TAR documented the PRN lorazepam concentrate 1 mg/0.5 ml was administered on 12/18/22. On 03/06/23 at 9:53 a.m., the DON was asked what was the protocol for use of PRN psychotropic medications. She stated they were limited to 14 days. She stated after the 14 days the use of the medication was reviewed and the physician was called. She was made aware of the residents PRN lorazepam order and where it had been administered on 12/18/22. She was asked if there was documentation to continue the use of the PRN medication past the 14 days. She stated she would look…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2026-03-25
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| TRUMBO, JAY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 08/01/2012 |
| VINSON, JOHN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 34% | since 08/01/2012 |
| CORR, MERICA | Individual | W-2 MANAGING EMPLOYEE | — | since 03/05/2021 |
| HEALTH SYSTEMS OF OKLAHOMA, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/24/2011 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $389K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375362. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-30, 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.