North County Center For Nursing And Rehabilitation
2300 West Broadway, Collinsville, OK 74021 · For profit - Corporation · 119 certified beds · (918) 371-2545 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Jul 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,641 in federal fines (most recent 2025-03-17)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.4% | 13.6% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.1% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.7% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.6% | 3.4% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.6% | 4.7% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.1% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.3% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 4.7% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 20.4% | 17.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.9% | 17.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 67.3% | 74.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.0% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.9% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.16 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.51 | 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.
58.8% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% 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 28 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 58.8%CMS range 44.8–74.7 | 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 | 10.5%CMS range 7.0–16.4 | 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 | 50.0% | 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 | 32.1% | 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 | 64.3% | 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 | 2.4% | 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 | 2.4% | 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 | 6.2%CMS range 3.1–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 119 beds and averages 53.3 residents a day — about 45% occupied, or roughly 66 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.51 on weekdays — 9% thinner on weekends. RN hours go from 0.27 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as 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
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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · J2025-03-17 · tag F0622 — isolatedNot 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 03/12/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were discharged with proper notice. On 03/06/25 Resident #1 returned to the facility after an overnight stay with family. Resident #1 was informed they were no longer a resident of the facility and were not allowed to return to the facility. On 03/12/25 at 5:57 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to a resident who was not allowed to return to the facility after an overnight stay with family. On 3/12/25 at 6:05 p.m., the DON and the corporate regional administrator were notified of the IJ situation and were asked to provide a plan of removal. On 03/13/25 at 2:35 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, North County Immediate Jeopardy Plan of Removal for Failure to Ensure Residents Are Not discharged Without Proper Notice 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.
- Actual harm · G2023-02-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to initiate fall interventions, to reduce the risk of a fall with major injury, for one (#23) of five residents sampled for falls. The Resident Census and Condition of Residents, form documented 39 residents resided in the facility. Findings: A Fall Prevention Program policy, dated 2022, documented in parts, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .interventions will be monitored for effectiveness . The plan of care will be revised as needed .When any resident experiences a fall, the facility will .document all assessments and actions . Resident #23 had diagnoses which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-06 · 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 observation, record review, and interview, the facility failed to ensure staff followed infection control practices between residents while administering medications for 3 (#9, 17, and #23) of 8 sampled residents reviewed for medication administration.The DON identified 43 residents were administered medications by facility staff.Findings:On 08/05/25 at 3:53 p.m. CMA #1 was observed going to their medication cart and preparing medications for Res #23. CMA #1 did not sanitize or wash their hands prior to preparing the medications. CMA #1 was then observed taking the plastic cup that contained Res #23's medication, hydrocodone/acetaminophen (pain medication) 7.5 mg / 325 mg tablet and handing it to Res. #23. Res #23 was observed placing the cup to their mouth and taking the medication. The resident was then observed returning the empty medication cup to CMA #1. On 08/05/25 at 3:57 p.m. CMA #1 was observed going to their medication cart and preparing medications for Res #17 directly after returning from administering medications to Res #23. CMA #1 did not sanitize or wash…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-06 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an antipsychotic medication was not prescribed for the diagnosis of dementia for 1 (#25) of 5 sampled residents reviewed for unnecessary medications.The DON identified five residents were prescribed antipsychotic medications.Findings:A facility policy titled Antipsychotic Medication Use, dated April 2007, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.A medication administration record for Res #25, dated 08/01/25 through 08/31/25, showed the resident had been prescribed Seroquel (an antipsychotic) 25mg tablets once in the morning and once at bedtime for unspecified dementia with unspecified severity, with other behavioral disturbances and anxiety. The record showed the resident had been administered the medication twice each day on 08/01/25, 08/02/25, 08/03/25, 08/04/25, and one dose on 08/05/25.On 08/05/25 at 11:49 a.m., CMA #3 was asked if they knew the reason Res #25 was being administered Seroquel. They…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an MDS discharge assessment record was transmitted in the required timeframe for 1 (#1) of 14 sampled residents reviewed for MDS assessments.The DON identified 44 residents required MDS assessments to be completed at the facility.Findings:A facility policy titled Electronic Transmission of the MDS, dated [DATE], read in part, All MDS assessments (eg. [for example], admission, annual, significant change, quarterly review, etc. [et cetera]) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES [Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations governing the transmission of MDS data.An undated Transfer/Discharge Report, for Res #1 showed the resident had been discharged from the facility on 03/01/25.On 08/05/25 at 10:33 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 · E2024-07-26 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
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 controlled medications were not misappropriated for three (#4, 7, and #8) of three sampled residents who were reviewed for misappropriation. The DON identified 42 residents who resided in the facility. Findings: The Controlled Substances policy, dated April 2019, read in part, .Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, read in part, .Residents have the right to be free from .misappropriation of resident property . 1. Resident #4 had diagnoses which included abnormal posture and weakness. Form 283, incident date 06/10/24, read in parts, .DON was notified that LTC resident has a missing narcotic of Hydrocodone 5-325 mg tab qty of 60 are unaccounted for. Medication was delivered on 6/5/24 by pharmacy; the total quantity delivered was 112 tabs. #1 card of 52 tabs is in facility in the med cart. On 6/9/24 the nurse on duty contacted the MD for an order for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — 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 complete a baseline care plan for three (#31, 45, and #246) of 12 residents whose care plans were reviewed. The DON identified 41 residents who resided in the facility. Findings: 1. Res #31 had diagnoses which included osteomyelitis, stage four pressure ulcer to the left heel, a stage three pressure ulcer to the right heel, diabetes, hypertension, and anxiety. Res #31 was admitted to the facility on [DATE]. The care plan, dated 01/04/24, documented a baseline care plan had been completed six days after admission. On 04/03/24 at 9:19 a.m., the care plan coordinator reviewed the resident's care plan and stated the baseline care plan was completed late. The coordinator stated they completed the baseline care plan upon returning to work. 2. Res #45 was admitted on [DATE] with diagnoses which included non-traumatic intracranial hemorrhage, hypertension, and dementia. The resident's EHR documented a baseline care plan which had been initiated on 02/13/24…
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.
- Potential for harm · E2024-04-04 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 to include the use of bed rails for four (#16, 23, 146, and #246) of four sampled residents reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails. Findings: A policy, titled Care Plans, Comprehensive Person-Centered, dated 03/2022, read in part The comprehensive, person-centered care plan .described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .and reflects currently recognized standards of practice for problem areas and conditions. 1. Resident #16 had diagnoses which included primary osteoarthritis. A physician's order, dated 11/21/23, documented the resident was allowed to use therapeutic devices as needed to assist with positioning changes. On 04/03/24 at 12:40 p.m., Resident #16 was observed to have an assist bar attached to the left side of their bed. A review of 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 · E2024-04-04 · tag F0700 — patternTry 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 attempt alternative interventions prior to the use of bed side rails for three (#16, 23, and #146) of three sampled residents reviewed for accident hazards and failed to assess resident's risk of entrapment prior to use of bed side rails for two (#16 and #146) of three sampled resident reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails. Findings: A policy titled, Bed Safety and Bed Rails, dated 08/2022, read in part, Prior to the installation or use of a side or bed rail, alternatives to the use of side of bed rails are attempted. The policy also documented that after alternatives were concluded to be ineffective the resident would be assessed for their risk associated with the use of bed side rails. 1. Resident #16 had diagnoses which included chronic pain and primary osteoarthritis. An MDS quarterly assessment, dated 02/27/24, documented the resident's cognition was severly impaired. A review of the resident's chart did not find documentation of the attempt to use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview the facility failed to complete required nurse aide yearly performance reviews for two (CNA #2 and CNA #4 ) whose employee files were reviewed for competencies. The DON identified 13 nurse aides currently employed by the facility. Findings: The employee file for CNA #2 documented the last skills performance was completed on 09/22/22. The employee file for CNA #4 documented the last skills performance was completed on 09/22/22. On 04/04/24 at 11:34 a.m., the DON reviewed the skills performance checklists provided for two CNAs currently working for the facility. The DON stated to their knowledge no skills performance checks had been completed for the year 2023 for current CNAs. The DON stated they were not aware of the requirement.
- Potential for harm · Ecited before2024-04-04 · 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 maintain an infection prevention and control program to prevent the transmission of infections: a) for resident #10 during catheter care, b) for resident #21 during incontinent care, and c) implement a water treatment program for the prevention of Legionella. The administrator identifed five residents with a catheter/receive incontinent care. Findings: A handwashing/hand hygiene policy documented .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based had rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . A policy titled Catheter Care, Urinary documented .Steps in the Procedure .2. Wash and dry your hands thoroughly .5. Put on gloves .11. With non-dominant hand .retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout 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 · D2024-04-04 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for two (#4 and #7) of two sampled residents reviewed for advanced directives. The DON identified 41 residents resided in the facility. Findings: 1. Res #4 had diagnoses which included chronic kidney disease - stage 3, type 2 diabetes mellitus with diabetic neuropathy, and chronic respiratory failure with hypoxia. The resident's clinical records did not document the resident and/or their representative was offered the choice to formulate an advanced directive. 2. Res #7 had diagnoses which included embolism and thrombosis of unspecified vein, edema, hypokalemia, and cerebral fluid drainage. The resident's clinical records did not document resident and/or their representative were offered the choice to formulate an advanced directive. On 04/01/24 at 10:46 a.m., the social service director stated the facility would starting scanning all advanced directives offered to the resident and/or representative whether they were accepted or refused to show they…
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 14 citations
- Potential for harm · D2024-04-04 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an admission assessment for residents were completed within the required timeframe for one (#246) of 13 residents whose assessments were reviewed. The DON identified 41 residents who resided in the facility. Findings: Res #246 had diagnoses which included congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome. Res #246 was admitted to the facility on [DATE]. The EHR did not document an admission assessment had been completed. On 04/03/24 at 1:40 p.m., MDS coordinator #1 stated the staff nurse assigned to complete the MDS assessments had been out for a family emergency. MDS coordinator #1 stated they have been doing all the assessment and had fallen behind.
- Potential for harm · D2024-04-04 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to complete a quarterly assessment within the required time frame two (#14 and #32) of 13 residents whose assessments were reviewed. The administrator identified 41 residents who currently resided in the facility. Findings: 1. Res #32 had diagnoses which included respiratory failure, congestive heart failure, and cerebrovascular disease. The EHR documented a quarterly assessment, dated 12/15/23, had been completed for the resident. The EHR documented a quarterly assessment, dated 03/15/24, was still in progress. On 04/03/24 at 11:54 a.m., the MDS coordinator reviewed the resident's EHR and stated the quarterly assessment dated [DATE] was not completed and should have been. The staff stated the facility was behind on completion of required MDS assessments. 2. Res #14 had diagnoses which included dementia, schizoaffective disorder, and auditory hallucinations. A quarterly MDS assessment, with an ARD date of 03/12/24, documented in progress on the MDS page of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-04 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 assessments were encoded and submitted to CMS within seven days of completion of the assessment for one (#16) of 13 residents whose assessments were reviewed. The administrator stated 41 residents were residing in the facility. Findings: Res #16 had diagnoses which included urinary tract infection and cellulitis. The resident's EHR documented a quarterly assessment had been completed on 02/27/24. The EHR documented the facility submitted the assessment on 04/03/24 during the survey. On 04/02/24 at 9:50 a.m., Res #16 was observed in a manual wheelchair moving toward their room. The resident stated they had been receiving an antibiotic for cellulitis in their right leg but did not think they were taking it anymore. On 04/03/24 at 11:59 a.m., MDS coordinator #1 stated someone at the corporate offices had submitted the assessment that morning. They stated the person who submitted the MDS assessment was offsite and not available for interview. The MDS coordinator stated they did not know why this assessment…
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 · D2024-04-04 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to develop a discharge summary including a recapitulation of the resident's stay, a reconciliation of the resident's medications, and a post discharge plan of care, for one (#44) of two residents reviewed for discharge from the facility. The DON identified 41 residents who resided in the facility. Findings: Res #44 had diagnoses which included fracture of the shaft of the right fibula, orthopedic after care, osteoarthritis, chronic stage four kidney disease, and diabetes. An admission assessment, dated 12/28/23, documented the resident was intact in cognition. A discharge, return not anticipated, assessment, dated 01/10/24, was documented in the resident's EHR. A social service note, dated 01/10/24, documented Res #14 was discharged from the facility to be admitted to another facility in a different state and would have been transported by a family member. The note documented the new facility had been contacted and were ready to admit the resident. On 04/02/24 at 11:00 a.m., MDS coordinator #1 stated the discharge summary…
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 · D2024-04-04 · 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 observation, record review, and interview, the facility failed to ensure the physician was notified of significant weight loss and failed to implement interventions to maintain and/or prevent further weight loss for one (#34) of two sampled resident reviewed for weight loss. The DON identified 41 residents who resided in the facility. Findings: Res #34 was admitted to the facility with diagnoses of tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis. On 04/19/23 the care plan documents offer supplements or alternates if resident east less than 50% of meals served, or refuses meals. An EHR entry, dated 01/02/24, documented Res #34 had a weight of 145.2 lbs. On 01/26/24 at 07:00 a.m., a dietary order documents, house supplement every day shift for weight loss. An EHR entry, dated 02/04/24, documented Res #34 had a weight of 137.4 lb., a weight loss of 7.8 lbs. A significant change assessment, dated 03/08/24, documented the resident was moderately impaired with cognition and was dependent with all ADLs. The assessment 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.
- Potential for harm · D2024-04-04 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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' nutritional issues were supervised by a physician for one (#34) of two residents sampled for weight loss. The DON identified 41 residents who resided in the facility. Findings: Res #34 was admitted to the facility with diagnoses of tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis. On 04/19/23 the care plan documents offer supplements or alternates if resident east less than 50% of meals served, or refuses meals. An EHR entry, dated 01/02/24, documented Res #34 had a weight of 145.2 lbs. On 01/26/24 at 07:00 a.m., a dietary order documents, house supplement every day shift for weight loss. An EHR entry, dated 02/04/24, documented Res #34 had a weight of 137.4 lb., a weight loss of 7.8 lbs. A significant change assessment, dated 03/08/24, documented the resident was moderately impaired with cognition and was dependent with all ADLs. The assessment documented the resident had experienced a significant weight loss. On 04/01/24 at 08: 40 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 · Dcited before2024-04-04 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to maintain an ice machine in a sanitary condition. The DON stated all 44 residents received ice from the ice machines. Findings: The facility's Sanitation policy, dated 11/2022, read in part, The food service area is maintained in a clean and sanitary manner. On 04/03/24 at 11:13 a.m., the DM wiped the inside of a ice machine located in a employee only hallway next to the kitchen. The cloth came back with a black substance covering it. The DM stated the ice machine provided ice to the residents. The DM stated the ice machine was cleaned once every six month. At 11:42 a.m., the administrator stated the ice machines were cleaned every six months and they would provide documentation of those cleanings. The administrator offered two invoice for inspection and cleaning of two ice machines, dated 12/29/23 and 01/31/24. They did not have any other documentation. On 04/04/24 at 8:05 a.m., the DM stated they had turned off the ice machine that was found to be dirty and the second had not been working for several weeks…
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 · D2024-04-04 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to conduct regular inspections of resident beds and failed to inspect resident beds for safety prior to the attachment and use of bedrails for three (#16, 23, and #146) of three sampled residents reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails. A Resident Listing Report, dated 04/01/24 documented 44 resident resided at the facility. Findings: A policy titled, Bed Safety and Bed Rails, dated 08/2022, read in part, Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. The policy also read Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. 1. Resident #16 had diagnoses which included chronic pain and primary osteoarthritis. An undated admission record documented the resident was admitted to the facility on [DATE]. A physician's order, dated 11/21/23, documented the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure physician orders were followed in relation to wound care for one (# 7) of three residents reviewed for wound care. The administrator reported the census was 41. Findings: An undated facility policy titled Wound Care read in part, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order for this procedure .Report other information in accordance with facility policy and professional standards of practice . Resident #7 had diagnoses which included a pressure ulcer of the sacral region and diabetes mellitus. An admission assessment, dated 11/24/23, documented Resident #7 was cognitively intact and was dependent on staff for transfer. A physician order, dated 02/20/24, documented the sacral wound was to be cleaned with normal saline and a wound vac was to be applied. A Wound Evaluation and Management Summary, dated 03/14/24, documented the wound vac on the sacral wound was to be discontinued and the wound was to be covered…
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 · E2024-01-29 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 the abuse policy was implemented for verbal abuse for one (#6) of five sampled residents who were reviewed for abuse. The administrator identified 46 residents who resided at the facility. Findings: The Abuse policy, dated 02/17/22, read in parts, .Verbal abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability .Identification .Administrative and licensed staff will be aware of potential situations of abuse during rounds and contact with staff, residents . Resident #6 had diagnoses which included impulse disorder and dementia. The Care Plan, dated 08/16/23, documented the resident could be moody if they did not get something they wanted. The Care Plan documented the resident liked to smoke, talk about things that made them happy, watch television, and staff should attempt those thing to change the resident's mood/behavior. A behavior 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.
- Potential for harm · E2024-01-29 · tag F0609 — failed to report abuse allegations — patternTimely 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 allegations of verbal abuse were reported to the administrator and OSDH for one (#6) of five sampled residents who were reviewed for abuse. The administrator identified 46 residents who resided at the facility. Findings: The Abuse policy, dated 02/17/22, read in parts, .Employees are required to report all incidents of possible abuse .immediately to their supervisor .The supervisor .shall immediately report to the Administrator or person on call .Nursing facility must report .immediately but not later than 2 hours after the allegation is made .The charge nurse will .Notify the Administrator or person on call, if after hours . Resident #6 had diagnoses which included impulse disorder and dementia. A behavior note, dated 08/22/23 at 10:23 a.m., documented Resident #6 began cursing at and calling another resident names. The note did not document the administrator or DON had been notified of the incident. The admission assessment, dated 08/24/23, documented Resident #6 was moderately impaired in cognition for daily…
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 · E2024-01-29 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure staff had received abuse training upon hire for four (CNA #1, CNA #2, CNA #3, and housekeeper #1) of five employee files reviewed for abuse training. The administrator identified seven employees hired in the past four months. Findings: The Abuse policy, dated 02/17/22, read in parts, .Training .All new employees will receive in-service training pertaining to all aspects of abuse prohibition before working a shift . 1. CNA #1 was hired on 01/04/24. 2. CNA #2 was hired on 11/11/23. 3. CNA #3 was hired on 11/21/23. 4. Housekeeper #1 was hired on 12/28/23. Review of the employee files did not reveal they had received abuse training upon hire. On 01/29/24 at 2:03 p.m., the DON stated the facility had not provided abuse training upon hire since they switched owners several months ago. On 01/29/24 at 2:28 p.m., the administrator stated they had not provided employee abuse training upon hire since the new company had taken over the facility in September 2023.
- Potential for harm · Ecited before2023-02-24 · 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 properly store and date food items to ensure food service safety. The facility reported 39 residents received meals from the facility kitchen. Findings: A facility policy titled Refrigerators and Freezers, revision date 2008, documented .This facilty will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines .All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on the cases and on the individual items removed from the cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. expiration dates on unopened food will be observed and use by dates indicated once food is opened. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. On 02/21/23 at 11:46 a.m., a tour of the facility kitchen was conducted. The following food items were observed to either be…
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 · D2023-02-24 · 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 update the plan of care with fall interventions for one (#23) of five residents sampled for falls with injuries. The Director of Nursing reported one resident with a fall with major injury. Findings: A Fall Prevention Program policy, dated 2022, documented in parts, .The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .interventions will be monitored for effectiveness . The plan of care will be revised as needed . Resident # 23 had diagnoses which included traumatic subdural hemorrhage without loss of consciousness, insomnia, persistent mood disorder, depression, anxiety, a history of cerebral infarction, and chronic pain. A Nurse Note, dated 12/30/22 at 1:40 p.m., documented resident #23 had a fall in the hallway. The note 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.
“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
$17,641 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $17,641 — penalty dated 2025-03-17
- Medicare payment denial — starting 2024-06-27 for 50 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RIVERS EDGE OPERATIONS II LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2023 |
| OELBAUM, YITZCHOK | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 15% | since 09/01/2023 |
| MANGANYA, RICHARD | Individual | W-2 MANAGING EMPLOYEE | — | since 09/01/2023 |
| GANZ, DAVID | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2023 |
CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
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 70% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375504. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-06, 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.