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Southern Pointe Living Center

101 Sherrard Drive, Colbert, OK 74733 · For profit - Corporation · 95 certified beds · (580) 296-4500 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 2025Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$38,445 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $38,445 in federal fines (most recent 2025-04-08)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (72%) 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1014 Memorial Dr Ste 212 · (903) 416-6350 · Call to confirm hours
Pharmacy
401 N Us Highway 75 · (903) 465-8035 · Call to confirm hours
Grocery
103 South Franklin St · (580) 296-2009 · Call to confirm hours
Park
0000-18-08S-08E-3-008-00 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 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 rating1★
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 increased23.8%13.6%15.4%worse
Long-stay residents who lose too much weight4.2%3.3%5.4%better
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 infection3.8%2.8%2.0%worse
Long-stay residents with depressive symptoms1.6%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 injury4.9%4.7%3.3%worse
Long-stay residents whose ability to walk worsened22.5%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication28.9%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine84.1%94.6%95.3%worse
Long-stay residents with pressure ulcers9.6%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control11.2%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table28.8%17.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication5.0%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine77.3%74.1%79.4%typical
Short-stay residents rehospitalized after admission38.0%27.3%22.6%worse
Short-stay residents with an outpatient ER visit13.6%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.732.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.382.961.80better

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

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

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

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

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

44.7% 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 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.7%U.S. median 51.5%
Got home and stayed home
12.6%U.S. median 10.7%
Went back to hospital
0.30U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNF44.7%CMS range 29.4–59.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.6%CMS range 9.0–18.310.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified76.5%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 setting96.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened7.8%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 hospitalization7.4%CMS range 3.9–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.371.02Oct 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

0.24
RN hours/ resident / day
0.44
LPN hours/ resident / day
1.19
Aide hours/ resident / day
1.87
Total nurse hours/ resident / day
0.27
RN hoursweekends
72.5%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 95 beds and averages 53.6 residents a day — about 56% occupied, or roughly 41 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 1.87 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.19 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.13 hrs/resident/day on weekends vs 1.76 on weekdays — about the same on weekends as weekdays. RN hours go from 0.23 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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 (2025-09-18)
11
at the previous standard inspection (2024-04-04)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2025-04-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 04/07/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect a resident's right to be free from neglect. Resident #3 admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. There was no documentation upon admission of Resident #3 having any skin issues. Resident #3's quarterly assessment, dated 01/13/25, showed the resident required substantial/maximal assistance with all ADL's and had a Braden score of 16, placing them at increased risk of pressure ulcer/pressure injury development. The assessment showed there were no skin concerns. There were no documented skin assessments between 01/26/25 and 02/10/25. A nursing note, dated 02/10/25 at 6:55 p.m., showed Resident #3 was transferred to hospital for altered mental status and slurred speech. There was no documentation of concerns related to the buttock or coccyx. A hospital…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2025-04-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 04/07/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident at risk for pressure ulcers was assessed and monitored to prevent pressure ulcers. Resident #3 admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. An admission assessment, dated 07/13/24, showed no skin concerns. Resident #3's quarterly assessment, dated 01/13/25, showed the resident required substantial/maximal assistance with all ADL's and had a Braden score of 16, placing them at increased risk of pressure ulcer/pressure injury development. The assessment showed no skin concerns. There were no documented skin assessments between 01/26/25 and 02/10/25. A nursing note, dated 02/10/25 at 6:55 p.m., showed Resident #3 was transferred to hospital for altered mental status and slurred speech. There was no documentation of concerns related to the buttock or…

    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 · E2025-09-18 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours a day for 2 of 3 months of time details for registered nurses reviewed.The administrator identified 42 residents resided in the facility.Findings:A Time Detail Report, dated 07/01/25 through 07/31/25, showed no RN hours for Friday, 07/11/25; Monday, 07/14/25; Monday, 07/28/25; and Tuesday, 07/29/25. A Time Detail Report, dated 08/01/25 through 08/31/25, showed no RN hours for Thursday, 08/07/25; Tuesday, 08/26/25; Friday, 08/29/25; and Sunday, 08/31/25.No other RN documentation was provided at the time of the survey.On 09/18/25 at 12:15 p.m., the business office manager stated the DON's last day of employment was Thursday, 06/20/25.On 09/18/25 at 2:13 p.m., the regional director of operations stated the RN called in Sunday, 08/31/25.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-04 · 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 observation, record review, and interview the facility failed to develop a comprehensive care plan related to nutrition and elopement for two (#22 and #50) of 12 residents reviewed for care plans. The DON identified 42 residents who resided in the facility. Findings: 1. Res #22 had diagnoses which included muscle wasting and atrophy, hypokalemia, and vitamin deficiency. An admission assessment dated [DATE], documented the resident was intact with cognition and had frequent pain. The assessment documented the resident weight was 241 pounds. The CAA area of the MDS triggered to care plan nutritional status. A quarterly assessment, dated 03/11/24 documented the resident was intact with cognition and documented the resident's weight was 205 pounds and was not on a physician prescribed weight loss program. On 04/01/24 at 12:53 p.m., the resident was observed in the recliner in their room. The noon meal had been served and he was not eating it. The resident stated they eat breakfast then they start having…

    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 before2024-04-04 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to follow physician orders for three (#1,#22, and #34) of 12 resident reviewed for following physician orders. The DON identified 42 residents who resided in the facility. Findings: 1. Res #22 had diagnoses which included muscle wasting and atrophy, hypokalemia, and vitamin deficiency. A quarterly assessment, dated 03/11/24 documented the resident was intact with cognition. The assessment documented the resident's weight was 205 pounds and was not on a physician prescribed weight loss program. Physician orders, dated 12/09/24, documented to document the amount consumed by the resident for breakfast, lunch, dinner and the amount of fluids consumed with the meals. The meal % documentation was not completed for all meals daily. The documentation was observed for the month of March and to April 4th. On 03/07/23, 03/09/24, 03/14/24, and 03/23/24 there was no meal % documented. On 04/04/24 at 1:30 p.m., The DON stated the meal % were just not being charted as ordered. 2. Res #1 had diagnoses which included diabetes A physician's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-04 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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 — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure menus were followed for one meal service for the puree meals. The DM identified three residents who eat a puree diet. Findings: On 04/03/24 11:18 a.m., the DM started the puree with cherry cobbler. At 11:27 a.m. the cabbage was pureed, at 12:04 pm., the sausage was pureed, and at 12:11 p.m. the potatoes were pureed. Corn bread for the puree meal was not observed. The menu for 04/03/24 was Kielbasa, fried potatoes, cabbage, cornbread, and fruit cobbler. The puree menu documented the residents were to receive a #10 scoop of cornbread. On 04/03/24 at 1:04 p.m., the DM stated the residents who have the pureed meals should have also received cornbread with their meal. The DM stated they were nervous and missed the corn bread.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0563 — failed to protect the right to visitors — isolated
    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
    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's rights to allow/receive visitors of the resident's choice for one (#33) of one sampled resident reviewed for visitation. The DON identified 42 resident who resided in the facility. Findings: An undated facility policy titled VISITING REGULATIONS, read in part, .Establish a measurable goal for active participation and social interaction with visitors of the resident's choice . Res #33 had diagnoses which included chronic pain syndrome, chronic kidney disease, and adjustment disorder with depressed mood. A five day assessment, dated 03/16/24, documented the resident was intact with cognition and required supervision or touch assistance with most ADLs. On 04/01/24 at 10:22 a.m., the resident councel president stated the can have visitors of choice. They stated Res #33 had talked to them about not being allowed visitor of choice. The resident councel president stated they had talked to the administrator and the ombudsman had been to the facility and now Res #33 can have the visitor of their choice. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0641 — isolated
    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 and interview, the facility failed to ensure resident assessments were accurate for two (#4 and #7) of 12 sampled residents whose resident assessments were reviewed. The DON identified 42 residents who reside in the facility. Findings: 1. Res #7 had diagnosis which included COPD, Bipolar disorder, Schizoaffective disorder, and dementia. A significant change assessment, dated 03/06/24, documented the resident was severly impaired with cognition and required partial to moderate assistance with most ADLs. The assessment documented a GDR had not been contraindicated. A MRR request, dated 09/27/23, documented the following medications are due for consideration of a GDR for clonazepam, Vraylar, and Risperdal. On 10/02/23 the physician did not wish to reduce the medication. The physician documented the resident was on hospice. On 04/03/24 at 2:12 p.m., the corporate nurse consultant #1 stated the contraindication should have been dated 09/27/23 on the MDS. 2. Res #4 had diagnoses which included osteoporsis. Progress notes dated 02/06/24 at 1:09 a.m., through 02/07/24…

    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 · D2024-04-04 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify OHCA of a new diagnoses of serious mental illness for one (#7) of one sampled resident whose PASRR I was reviewed. The DON identified 42 residents who resided in the facility. Findings: Res #7 was admitted to the facility on [DATE] and had diagnoses which included Schizoaffective disorder and major depressive disorder. On 11/07/22 A PASRR I was completed. The PASRR I did not document the resident had a serious mental illness. On 12/30/22, the resident received a new diagnosis of Bipolar disorder, unspecified. OHCA was not contacted regarding the new diagnoses. On 04/04/24 at 8:45 a.m., corporate nurse #1 confirmed OHCA was not called when the resident got a new diagnoses in December of 22.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a PASRR I for a newly admitted resident who remained in the facility for one (#7) of one sampled resident whose PASRR I was reviewed. The DON identified 42 residents who resided in the facility. Findings: Res #7 had was admitted to the facility on [DATE] and had the diagnoses of Schizoaffective disorder. A PASRR I was not located as completed on admission. On 02/14/22 the resident received the diagnosis of major depressive disorder, recurrent, moderate. On 11/07/22 A PASRR I was completed. The PASRR I did not document the resident had a serious mental illness. On 12/30/22, the resident received a new diagnosis of Bipolar disorder, unspecified. On 04/04/24 at 8:47 a.m., corporate nurse #1 stated the PASRR I was completed late they were not able to fine a PASRR I on admission.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a resident at risk for elopement was properly assessed and monitored to prevent elopement from the facility for one (#50) of two residents reviewed for elopement risk. Findings: The Elopement policy, undated, read in part, .Upon admission, quarterly and with significant change in status, the nurse will completed an Elopement Screen. Those residents will have an Elopement Risk Alert completed . Res #50 had diagnoses which included dementia and mood disorder. An LTC - admission Assessment/Observation Documentation, dated 11/01/23, documented Res #50 was an elopement risk. A progress note, dated 11/28/23 at 2:35 a.m., documented the resident eloped from the facility through a torn window screen. A progress note, dated 11/28/23 at 1:57 p.m., documented the resident was located at 5:45 a.m. and would be transferred to a geri-psych facility. A progress note, dated 12/18/23, documented the resident returned to the facility from geri-psych. Res #50's comprehensive care plan did not include an elopement risk care plan at the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 pain assessments for two (#10 and #24) of two resident reviewed for pain. The DON identified 42 residents who resided in the facility. Findings: The Pain - Clinical Protocol policy, last revised October 2010, read in part, .2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is an onset of new or worsening of existing pain. 3. The staff will staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. 1. Res #10 had diagnoses which included pain. An annual assessment, dated 01/17/24, documented the resident was moderately impaired with cognition and was independent with most ADLs. The assessment documented the resident had occasionaly pain that affected sleep and interfered with activities. The assessment documented the resident received PRN pain medication. The resident did not have any 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-04-04 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 complete a MRR in the required time frame for one (#7) of five residents reviewed for unnecessary medications. The DON identified 42 residents who resided in the facility. Findings: An undated facility policy Medication Monitoring Medication Regimen Review and Reporting, read in part .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days . Res #7 had diagnoses which included bipolar disorder, major depressive disorder, and schizoaffective disorder. A MRR, dated 02/21/24, documented lorazepam 1 mg every six hours PRN anxiety or lorazepam 2 mg/ml 0.25 ml (0. 5mg) every two hours PRN anxiety/restlessness. The MRR documented are both of the above orders needed at this time or could one be stopped. The physician documented to discontinue the lorazepam 2 mg/ml every two hours PRN anxiety/restlessness. The MRR was dated 04/02/24. The GDR request was not completed in the 30 time frame in the facilities MRR policy. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure residents did not receive psychotropic medication, unless for a specific diagnoses condition for one (#7) of five residents reviewed for unnecessary medication. The DON identified 42 residents who resided in the facility. Findings: Res #7 had diagnoses which included bipolar disorder, major depressive disorder, and schizoaffective disorder. A significant change assessment, dated 03/06/24, documented the resident was severly impaired with cognition and had inattention and altered level of consciousness that comes and goes. the assessment documented the resident received an antipsychotic, antianxiety, antidepressant , and a hypnotic during the look back period. A physician order, dated 05/03/23, documented risperidone 0. 5 mg daily for major depressive disorder. A physician order, dated 05/03/23, documented Vraylar 1.5 mg administer daily for major depressive disorder. A physician order, dated 05/19/23, documented clonazepam administer 0.5 mg TID for schizoaffective disorder. A physician order, dated 02/21/24,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-02 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to protect the resident's right to privacy of personal and medical record information for one (#1) of one sampled resident whose medical records were reviewed. The Resident Roster, dated 12/29/23, documented a census of 45 residents. Findings: Res #1 had diagnoses which included Alzheimer's dementia, rheumatoid arthritis, and convulsions. An event report, dated 11/26/23, time unknown, documented the resident had a fall with injury which required transfer to the local hospital for evaluation. A 30 day discharge notice, dated 12/08/23, which was given to the resident's POA, read in part, .By this letter, I am informing you that a decision has been made to discharge [Res #1 name withheld] from our facility on January 9th, 2024 .[Res #1 name withheld] is being discharged because the facility cannot meet the resident's needs .We are sorry that it has come to this, but we feel you have left us with no other options . On 12/29/23 at 4:23 p.m., the POA reported…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-02 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to document the required information regarding an involuntary discharge in the medical record for one (#1) of one sample resident who was reviewed for discharge. The Resident Roster, dated 12/29/23, documented a census of 45 residents. Findings: Res #1 had diagnoses which included Alzheimer's disease, rheumatoid arthritis, and convulsions. On 12/08/23, Res #1's, POA, was given a 30 day discharge notice. The notice, read in part, .By this letter, I am informing you that a decision has been made to discharge [Res #1 name withheld] from our facility on January 9th, 2024 .[Res #1 name withheld] is being discharged because the facility cannot meet the resident's needs .We are sorry that it has come to this, but we feel you have left us with no other options . A Second Summary Order Overruling Involuntary Discharge, dated 12/21/23, read in part, .the facility failed to comply .When the facility transfers or discharges a resident under any of the circumstances specified .the resident's clinical record must be documented. 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 · Dcited before2024-01-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a fall with injury was documented in the medical record and the resident was monitored appropriately post fall for one (#1) of one sampled resident who was reviewed for a fall. The Resident Roster, dated 12/29/23, documented a census of 45 residents. Findings: A Fall - Evaluation and Prevention policy, last revised on 12/2019, read in part, .If there was a loss of conscious [sic] or the fall was unwitnessed, neuro signs should be initiated .Following a fall, the following steps should be undertaken .Complete an incident and accident report . An undated Condition change, of the resident (observing, recording and reporting) policy'', read in part, 1. After all resident falls, injuries or changes in physical or mental function .3. Complete an incident, accident or risk management report .5. Monitor resident's condition frequently . Res #1 had diagnoses which included Alzheimer's disease, rheumatoid arthritis, and convulsions. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-14 · 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

    Based on record review, observation, and interview, the facility failed to ensure a comprehensive care plan was developed to meet the residents' medical and nursing needs for five, (#4, 5, 15, 23, and #95) of five sampled residents whose care plans were reviewed. The facility failed to: a. develop a care plan for lymphedema for Res #4; b. develop a care plan for an indwelling urinary catheter for Res #5 and #15; c. develop a care plan for a PEG tube for Res #15; d. develop a care plan for oxygen therapy for Res #23 and e. develop a care plan for IV therapy for Res #95 The Resident Census and Conditions of Residents, completed on 01/10/23, documented a census of 35 residents. Findings: 1. Res #4 was admitted with diagnoses which included left sided mastectomy (removal of breast) and left arm lymphedema (swelling). A nursing note, dated 09/22/22 at 11:53 p.m., read in parts, .Pt. arrived to the facility .at 5:20 p.m. Pt. has had a L mastectomy removal .Pt has lymphedema in L arm. An admission assessment, dated 10/02/22, read in part, .upper extremity impairement to one side . 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-14 · 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 record review, observation, and interview, the facility failed to ensure a comprehensive care plan was revised regarding fall interventions for two, (#22, and #23) of five sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents, completed on 01/10/23, documented a census of 35 residents. Findings: A Falls - Evaluation and Prevention Policy, dated 3/2015, read in parts, .It is the policy of this facility to evaluate residents for their fall risk and develop interventions for prevention .Following a fall, the following steps should be undertaken: .Review all falls immediately .and CP updating. Fall interventions are to be reviewed for appropriateness, to ensure that they are a new intervention, and to ensure that they have been implemented . 1. Res #22 was admitted with diagnoses which included muscle wasting/atrophy, lack of coordination, and difficulty walking. A nursing note, dated 03/08/22 at 10:53 a.m., read in parts, Resident fell while trying to get out of her recliner. No bruising or abrasions noted . A nursing note, 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 before2023-01-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to assess fall risk for six (#4, 9, 22, 23, 33 and #94) of six residents reviewed for falls. The All Falls for Facility report, dated 01/10/22 through 01/10/23, documented 21 residents had falls in 2022. A Falls - Evaluation and Prevention Policy, revised 12/19, documented in part, It is the policy of this facility to assess/evaluate each resident for the potential for falls and fall risk and implement interventions for fall prevention as indicated .Residents should be evaluated for their fall risk .on admission .following a fall .quarterly . 1. Res #4 was admitted with diagnoses which included osteoporosis and dementia. A nursing note dated, 01/08/23 at 8:53 p.m., read in parts, Res found in floor by this nurse . There was no fall risk assessment completed upon admission, quarterly, or after the fall on 01/08/23. 2. Res #9 was admitted with diagnoses which included muscle wasting/atrophy, difficulty walking, and muscle weakness. A nursing note, dated 10/24/22 at 4:18 a.m., read in parts, .She was on the floor…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-14 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure nursing staff had demonstrated competencies to care for one (#95) of one resident reviewed for IV therapy. The corporate RN reported the facility had eight residents with IV therapy in the past 12 months. Findings: A Central Venous Catheters policy, dated 2003, documented in parts .the facility will require that the nurse(s) accessing or utilizing the CVC site to be qualified to do so. RNs may access/use the site when prior experience and/or training have been completed .RNs who have not had experience or training .will receive additional training/education .and will demonstrate competency prior to accessing or utilizing .The LVN/LPN may access/use the site when documented IV certification and competency specific .have been demonstrated. The qualified RN may verify competency for the CVC procedures .Nurses should NEVER perform a procedure that they are not qualified to perform regardless of instruction to do so by the physician or employer . Res #95 was admitted with diagnoses which included pseudomeningocele (an…

    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 · Dcited before2023-01-14 · tag F0641 — isolated
    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 resident assessments were accurate regarding falls and an indwelling urinary catheter for two (#9 and #15) of five residents whose assessments were reviewed. The DON identified two residents with indwelling urinary catheters. The All Falls for Facility report, dated 01/10/22 through 01/10/23, reported 21 residents had falls in 2022. Findings: 1. Res #9 was admitted with diagnoses which included muscle wasting/atrophy, difficulty walking, and muscle weakness. A nursing noted, dated 10/24/22 at 4:18 a.m., read in parts, .She was on the floor in her room @ 2320 PM & states that she slipped off the bed . A quarterly resident assessment, dated 12/09/22, did not document any falls. The fall for 10/23/22 should have been documented on the quarterly resident assessment. On 01/11/23 at 11:00 a.m., the MDS Coordinator reported the fall on 10/23/22 should have been documented on the 12/09/22 resident assessment. 2. Res #15 was admitted with diagnoses which included dementia and diabetes. A physician's order,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and interview, the facility failed to provide care and services for the resident's highest possible level of functioning and well being for one (#95) of one resident sampled for IV therapy. The Resident Census and Conditions of Resident, dated 01/10/23 documented a census of 35 residents. Findings: Res #95 was admitted with a PICC (peripherally inserted central catheter). A physician's order, dated 09/23/22, documented, cefepime in sodium chloride 0.9% 100 ml powder; 2 Gram; amt: 1 bag; intravenous every 12 hours. A physician's order, dated 09/23/22, documented, vancomycin intravenous 1 gram with sodium chloride 0.9% 250 ml powder; 1 gram; intravenous once a day. A Medication Administration Record, dated 09/01/22 to 09/30/22, documented Res #95 received cefepime in sodium chloride 0.9% 100 ml powder: 2 gram;amt; 1 bag. intravenous twice a day at 8:00 a.m. and 8:00 p.m. from 09/24/22 through 09/30/22 and Vancomycin intravenous 1 gram with sodium chloride 0.9% 250 ml powder; 1 gram; intravenous once a day at 1:00 p.m. A Medication Administration Record, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure one (#15) of two residents reviewed for an indwelling urinary catheter was evaluated for continued use of an indwelling urinary catheter. The DON identified two residents with an indwelling urinary catheter. Findings: Res #15 was admitted with diagnoses which included aspiration pneumonia, dementia, and diabetes. A nursing note, dated 11/01/22 at 12:16 a.m., read in parts, Pt returned to facility via EMS from (name withheld) .Pt has 16 Fr foley catheter in place . A physician's order, dated 12/16/22, read in part, Foley Catheter in place 16 FR. with a 10 ml cc bulb .May change f/c q month on the 16th . The facility did not provide a policy regarding indwelling urinary catheters or a catheter assessment. On 01/10/22 at 10:00 a.m., resident was observed to be lying in bed on their right side with head of bed elevated with an indwelling urinary catheter in place. On 01/13/22 at 3:18 p.m., the DON reported they were unable to locate a catheter assessment for Res #15. On 01/14/22 at 4:00 p.m. family member…

    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 · D2023-01-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 record review, observation, and interview, the facility failed to follow their facility policies for one (#23) of one resident reviewed for oxygen therapy. The DON identified two residents who were on oxygen therapy. Findings: An Oxygen Administration policy, revised October 2010, read in parts, .The purpose of this procedure is to provdie guidelines for safe oxygen administration .1. Verify that there is a physician's order .Review the physician's order for oxygen administration . A Departmental (Respiratory Therapy) - Prevention of Infection policy, revised October 2010, read in parts, .use sterile water for humidification. [NAME] bottle with date and intials upon opening and discard after twenty-four (24) hours .Change the oxygen cannulae and tubing every seven (7) days, or as needed . Res #23 was admitted with diagnoses which included chronic obstructive pulmonary disease and congestive heart failure. Res #23's health record did not contain a current physician's order for oxygen administration or changing and labeling of tubing and humidifier bottle. On 01/10/23 at 9:30…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$38,445 in federal fines across 1 penalty.

  • $38,445 — penalty dated 2025-04-08

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.

Part of a chain

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

RatingThis homeChain avg
Overall 1 of 51.8-0.8 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 1 of 52.1-1.1 vs chain
Quality measures 1 of 52.5-1.5 vs chain
The other 14 homes this chain runs (chain average 1.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
BYPASS TR CU GILBERT F GREEN TROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 12/06/2021
MRTL DEDUCTION TR CU GILBERT F GREEN TROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST6%since 12/07/2021
PHILIP M. GREEN REVOCABLE TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST25%since 12/28/2020
PHILIP MARION GREEN EXEMPT TR CU GILBERT F GREEN TROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 12/08/2021
TIFFANY SEAY EXEMPT TROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 04/06/2022
MITCHELL, KELLYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 12/28/2020
MITCHELL, MARCINDAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 12/28/2020
MITCHELL, ROBERTIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 12/28/2020
TABOR, ANGELAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 12/28/2020
TAYLOR, SANDRAIndividualW-2 MANAGING EMPLOYEEsince 12/28/2020
BELT, MIRANDAIndividualCORPORATE OFFICERsince 12/09/2024
PITTS, JACIIndividualCORPORATE OFFICERsince 12/09/2024

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$3.2M
Net patient revenuemost recent cost report
-1.6%
Operating marginrevenue minus expenses
$326K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 15%Other / private 16%

This home reported $326K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$250per resident / day
operating cost
$7,586per month
≈ monthly operating cost
$246per 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 375469. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-18, 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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