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Coweta Care & Rehab Center

30049 East 151st Street South, Coweta, OK 74429 · For profit - Limited Liability company · 100 certified beds · (918) 559-2006 Medicare & Medicaid certified

Call the home — (918) 559-2006 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • nursing-staff turnover (57%) 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
11495 Oklahoma 51 · (918) 727-2780 · Call to confirm hours
Pharmacy
114 N Broadway · (918) 486-2193 · Call to confirm hours
Grocery
29220 E 151st St S · (918) 212-0992 · Call to confirm hours
Park
14024 S 283rd East Ave · Typically dawn to dusk
Place of worship
14533 S 302nd East Ave

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 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 rating4★
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 increased2.7%13.6%15.4%better
Long-stay residents who lose too much weight0.4%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.8%2.0%better
Long-stay residents with depressive symptoms3.4%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 injury3.5%4.7%3.3%typical
Long-stay residents whose ability to walk worsened5.8%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication26.5%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.7%94.6%95.3%typical
Long-stay residents with pressure ulcers5.0%4.7%4.7%typical
Long-stay residents with worsening bladder/bowel control10.1%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.3%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine74.4%74.1%79.4%typical
Short-stay residents rehospitalized after admission30.2%27.3%22.6%worse
Short-stay residents with an outpatient ER visit14.7%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.772.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.232.961.80better

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.

43.8% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.8%U.S. median 51.5%
Got home and stayed home
12.5%U.S. median 10.7%
Went back to hospital
71.4%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 71.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF43.8%CMS range 27.8–58.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.5%CMS range 9.4–17.910.7%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 discharge71.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge71.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge71.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.5–11.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.311.02Oct 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

0.11
RN hours/ resident / day
1.03
LPN hours/ resident / day
2.80
Aide hours/ resident / day
3.94
Total nurse hours/ resident / day
0.12
RN hoursweekends
57.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 100 beds and averages 78.9 residents a day — about 79% occupied, or roughly 21 beds typically open. It usually has some room. 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.11 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.64 hrs/resident/day on weekends vs 4.07 on weekdays — 11% thinner on weekends. RN hours go from 0.11 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%.

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

Inspection trend

4
deficiencies at the latest standard inspection (2025-11-21)
13
at the previous standard inspection (2024-05-03)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2023-03-27 · 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 record review and interview, the facility failed to ensure surgical wound treatment orders were obtained and treatments were provided for one (#69) of three residents who were reviewed with wounds. The DON identified one resident with a surgical wound. Findings: A Physician's Orders policy, dated December 2018, read in parts, .At the time each resident/patient is admitted , the facility will have Physician's orders for their immediate care . An Emergency Physician Care policy, dated December 2018, read in part, .Contact the facility's Medical Director or their alternate in the event Physician services are required and the attending and/or on-call Physician cannot be reached . Resident #69 was admitted on [DATE] with diagnoses which included partial traumatic amputation of two or more left toes. The Hospital Discharge Summary, dated 01/25/23, read in part, .Admit Diagnoses .Right foot osteomylitis s/p transmetatarsal amputation w/ subsequent partial wound dehicence [sic] . Review of the discharge…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0641 — isolated
    Ensure each resident receives an accurate 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 accurate assessments were completed for 2 (#5 and 81) of 28 sampled residents reviewed for accuracy of assessments. The administrator identified 75 residents resided in the facility. Findings: A facility MDS 3.0 policy, revised [DATE], read in part, Everyone completing a portion of the assessment must sign and certify the accuracy of the portion of the assessment they completed. 1. A physician's order for Resident #5, dated [DATE], showed to administer Clopidogrel Bisulfate (an antiplatelet) 75 mg one time a day for blood clot prevention. A quarterly assessment, dated [DATE], showed a BIMS of 10 which indicated Resident #5 had moderate cognitive impairment for daily decision making and diagnoses which included non-Alzheimer's dementia, traumatic brain injury, depression, anemia, and asthma. Section N of the assessment showed an anticoagulant was taken during the look back period and an antiplatelet was not taken. On [DATE] at 9:31 a.m., the MDS…

    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 · D2025-11-21 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to make a referral to the OHCA after a newly identified serious mental health disorder and a significant change in status assessment for 1 (#13) of 2 sampled residents reviewed for PASRR.The administrator identified 32 residents with mental health diagnoses. Findings: A PASRR level l form, dated 04/25/25, showed Resident #13 did not have a diagnosis of a mental health disorder and a PASRR level ll referral was not needed. An undated medical diagnosis tab in Resident #13's electronic medical record showed a diagnosis of bipolar disorder was added on 06/26/25. A significant change assessment, dated 07/29/25, showed Resident #13 had a BIMS score of 15 which indicated their cognition was intact. The assessment showed the resident was not currently considered by the state PASRR level ll process to have a serious mental illness and/or intellectual disability. On 09/22/25 at 4:41 p.m., the MDS coordinator stated they could not find documentation a referral was made to the OHCA for a PASRR level ll when the resident received the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 store drugs and biologicals in a locked compartment and permit only authorized personnel to have access for 1 of 3 nurse medication carts observed. The administrator identified 75 residents resided in the facility.Findings:Findings: On 09/17/25 at 8:27 a.m., an observation of a medication cart on the Southwest corridor was made. The cart was unlocked with a set of keys hanging from the lock. There were no staff present in the hall. Three residents were moving in the hallway independently. On 09/17/25 at 4:16 p.m., LPN #1 was observed during a medication pass on the Southwest corridor. LPN #1 obtained Pyridostigmine Bromide (a reversible acetylcholinesterase inhibitor medication) 60 mg and Pepcid (a H2 receptor which decreases gastric acid) 40 mg for Resident #31. LPN #1 removed the medication from the multi-dose pharmacy prepared package, placed the medication in a cup, and entered the resident's room to administer the medication. LPN #1 did not place the multi-dose medication packages back in the locked cart…

    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 · D2025-11-21 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure pureed food was free of chunks and of a consistency to meet the needs of the residents for 1 of 1 observation. The administrator identified four residents who ate pureed food from the kitchen. Findings: On 09/16/25 at 11:25 a.m. cook #1 was observed to prepare puree for the noon meal. The meatloaf was placed in the food processor with a low sodium beef base paste and hot water. When cook #1 thought the puree was finished, they asked the dietician to check the puree. This surveyor tasted the puree, and it was chunky with bits that required chewing. The dietician was not observed to taste the meatloaf puree and informed cook #1 it was good to serve. [NAME] #1 poured the puree into a container and placed it on the steam table to serve. On 09/16/25 at 11:55 a.m., the pureed meat was observed to be placed in a bowl with gravy added and placed on tray. On 09/16/25 at 11:57 a.m., this surveyor stopped the serving of puree. On 09/16/25 at 11:58 a.m., the dietary manager stated the puree was grainy and not smooth. They pulled…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure enhanced barrier precautions were provided during incontinent care and failed to ensure hand hygiene was performed during incontinent care for one (#7) of two sampled residents reviewed for incontinent care. The DON identified 16 residents on enhanced barrier precautions and 39 residents who required incontinent care. Findings: A facility policy titled Enhanced Barrier Precautions, reviewed 05/15/24, read in part, .Examples of High-Contact Resident Care Activities requiring Gown & Glove Use for EBP .Changing Briefs or Toileting . A facility policy titled Incontinent Care, reviewed 07/21/22, read in part, .Remove Soiled Brief .Cleanse Perineal Area .Remove Soiled Gloves, Perform Hand Hygiene & Apply Clean Gloves .Apply Clean Brief and Clothing . Resident #7 had diagnoses which included gastrostomy status and acute respiratory failure. On 10/15/24 at 11:19 a.m., CNA #2 was observed providing incontinent care to Resident #7 with the assistance of CNA #3. Neither staff member was observed wearing a gown. CNA #2 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure three of three shower rooms, which contained chemicals were locked and secure. The DON identified 73 residents resided at the facility. Findings: On 04/29/24 at 8:43 a.m., a shower room on hall #2 with unsecured chemicals was observed to not be locked. The following chemicals were observed: a spray bottle with green liquid approximately 18 ounces unlabeled, a spray bottle of bold Power hard surface and glass cleaner approximately 10 ounces, a purple top Sani-cloth tub, both labeled to keep out of reach of children. Three cans of shaving cream, two french lavender body scrub jars 5 ounces each state keep out of reach of children, one and one half gallons of shampoo & body wash, labeled to keep away from children and a razor without a safety cap. On 04/29/24 at 8:53 a.m., the hall #4 shower room door was observed to be unlocked with the following chemicals unsecured: spray bottle with 4oz unlabeled purple liquid, super sani wipes,…

    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 · E2024-05-03 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    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 on antipsychotic medications were assessed for tardive dyskinesia for three (#3, 34, and #32) of five sampled residents reviewed for unnecessary medications. The administrator identified 50 residents who received psychotropic medications. Findings: The Psychotropic Management Guidelines policy, dated 07/26/23, read in part, .Licensed Nurse will complete Psychoactive Medication Review on Admission, Quarterly, and Annually, and as needed . 1. Resident #3 had diagnoses which included paranoid schizophrenia. The Medical Director/Director of Nursing Consolidated Report from the pharmacist, dated 05/03/23, read in part, .Please ensure AIMS evaluation is done quarterly while taking antipsychotic medications . The Notes to Nursing form from the pharmacist, dated 06/08/23, read in part, .Please ensure AIMS evaluation is done quarterly while taking antipsychotic medications . Review of the electronic clinical record revealed the last AIMS assessment had been completed on 10/08/23. A Physician Order, dated 03/03/24,…

    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 · E2024-05-03 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure snacks were offered in the evening for seven (#8, 13, 53, 63, 79, 41, and #39) of seven sampled residents reviewed for snacks. The administrator identified 73 residents who received meals from the kitchen. Findings: The Meals and Snacks policy, dated 03/31/21, read in part, .Nursing shall be responsible for distributing snacks to the residents .An evening snack shall be provided by Nutritional Services and offered to the residents by Nursing .Nursing shall be responsible for offering and/or distributing snacks . On 05/01/24 at 1:30 p.m., Resident #39 and Resident #41 stated staff did not offer snacks in the evening. They stated they had to go to the nurses station to request one. On 05/01/24 at 8:52 p.m., four residents were observed in wheelchairs at the front nurses station requesting a snack. LPN #3 obtained snacks for the residents. Other staff were not observed offering snacks to the residents in their rooms. On 05/01/24 at 8:56 p.m., Resident #79 stated they had not been offered an evening snack.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-03 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure infection control protocols were followed during medication administration. The administrator identified 73 residents who received medications. Findings: The Super Sani-cloth germicidal disposable wipe directions read in parts, .Special instructions for cleaning and decontamination against HIV-1, hepatitis B virus (HBV) .All blood and other bodily fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Open, unfold and use first germicidal wipe to remove visible soil .Kills HIV-1 .precleaned environmental surfaces .previously soiled with blood/body fluids . On 05/01/24 at 10:55 a.m., LPN #2 entered the room for Resident #36 to check their blood sugar with a glucometer that was not properly sanitized. LPN #2 wiped the glucometer with a Sani-wipe but did not wait the full two minutes and wipe it again to ensure blood borne pathogens were eradicated. LPN #2 returned to the cart, did not sanitize their hands, drew insulin into a syringe, then returned to 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-03 · tag F0576 — isolated
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure mail delivery to residents on Saturdays. The DON identified 73 residents who resided in the facility. Findings: On 05/01/24 at 1:30 p.m., during a resident group meeting, four residents stated mail was not delivered on Saturdays. On 05/02/24 at 4:25 p.m., the activity director stated they obtained mail from the post office and delivered it to the residents Monday through Friday. They stated they did not know if anyone delivered mail to the residents on Saturdays. On 05/02/24 at 4:30 p.m., the administrator stated they delivered mail to the residents Monday through Friday but no one delivered mail to the residents on Saturdays.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-05-03 · 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, it was determined the facility failed to ensure the discharge was documented in the resident medical record for one (#78) of one sampled resident for discharge. The administrator identified 73 residents who resided in the facility. Findings: Resident #78 had diagnoses which included type two diabetes. Review of the medical record for Resident #78 revealed no documentation notification was provided to the physician or resident representative of the transfer. A nurse's note, dated 03/04/24, documented a phone call to an unidentified hospital inquiring about the condition of Resident #78. On 05/01/24 at 1:35 p.m., LPN #1 stated they did not know why Resident #78 was transferred but the reason should be in the medical record. They stated the reason for the transfer could be found in the medical record. After reviewing the medical record LPN #1 stated there was no note regarding the transfer of Resident #78. On 05/02/24 at 9:20 a.m., the administrator stated Resident #78 was transferred during the transition period to an electronic medical record…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-03 · 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 assessments were accurate for one (#55) of 24 sampled residents whose assessments were reviewed. The MDS coordinator identified eight residents who received anticoagulant medications. Findings: The MDS 3.0 policy, dated 04/26/23, read in parts, .The MDS coordinator and/or IDT will use the following when completing the assessment as directed by the RAI User's Manual .Documentation in the Medical Record . Resident #55 had diagnoses which included hypertension. The quarterly assessment, dated 02/28/24, documented the resident had received an anticoagulant medication during the seven day look back period. The Medication Administration Record, dated 02/01/24 through 02/29/24, did not reveal Resident #55 had received an anticoagulant medication during the seven day look back period. On 05/02/24 at 11:36 a.m., the MDS coordinator stated they had reviewed the clinical record and had coded the anticoagulant use because the resident was administered Plavix (an antiplatelet medication). They stated they would need to submit 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 · D2024-05-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure dependent residents were offered/received baths according to preference for one (#15) of one sampled resident who was reviewed for ADLs. The administrator identified 58 residents who were dependent for ADLs. Findings: An ADL Care Bathing policy, dated 07/21/22, read in part, .Nursing staff will assist in bathing Residents to promote cleanliness and dignity . Resident #15 had diagnoses which included colostomy status and acute kidney failure. A quarterly assessment, dated 04/17/24, documented Resident #15 required partial to moderate assistance for bathing and was moderately impaired in cognition for daily decision making. On 04/29/24 at 1:33 p.m., Resident #15 was observed to have oily hair. Resident #15 stated they received approximately one shower per week. A Care Plan, revised 04/30/24, documented Resident #15 required one person assistance with bathing and to offer a bed bath when a shower was not tolerated or was contraindicated. The Task documentation in the electronic clinical 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 · D2024-05-03 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure range of motion interventions were implemented for one (#47) of one sampled resident who was reviewed for limited range of motion. The administrator identified 20 residents who had limited range of motion. Findings: The Establishment of an Individual Restorative Program policy, dated 01/01/14, read in part, .To provide treatment and services to maintain and improve functional abilities per physician orders . Resident #47 had diagnoses which included impingement syndrome of the right and left shoulders. A Physician Order, dated 09/23/22, documented restorative therapy. The Restorative Training form, dated September 2023, documented to remove Resident #47 from the restorative nursing program. On 04/29/24 at 11:56 a.m., Resident #47 stated the last two fingers on their left hand was contracted. They stated they did not receive splints or devices for the contracture. Resident #47 stated one staff member would provide range of motion exercises at times but not consistently. The Care Plan, revised 04/30/24,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-03 · 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 observation, record review, and interview, the facility failed to ensure the urinary drainage bag was properly positioned for one (#48) of one resident observed for urinary catheter. The Resident Matrix documented six residents who had a catheter. Findings: Resident #48 had diagnoses which included hydronephrosis with renal and ureteral calculus. The Care Plan, revised 02/06/24, documented the resident had a nephrostomy tube related to ureteral obstruction, specimens should be obtained from the nephrostomy tube by gravity, and the drainage bag should be maintained in a position below the level of the kidney at all times. The quarterly assessment, dated 04/17/24, documented the resident was cognitively intact for daily decision making. On 04/29/24 at 1:35 p.m., Resident #48 was observed lying in bed with the nephrostomy drainage bag on a towel, on the bed, by the resident's feet. On 05/01/24 at 3:48 p.m., Resident #48 was observed lying in bed with the nephrostomy drainage bag on a towel, on the bed by the resident's feet. On 05/03/24 at 10:58 a.m., CNA #2 stated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure weights were monitored as recommended by the registered dietitian for one (#56) of one sampled resident for nutrition. The administrator Identified 73 residents who resided in the facility. Findings: Resident #56 had diagnoses which included adult failure to thrive and dementia. The electronic health record, dated 03/07/24, documented a weight of 133.2 pounds. On 04/01/24 the electronic health record documented a weight of 113.2 pounds, a loss of 20 pounds in 30 days. On 05/03/24 at 10:44 a.m., the registered dietician stated they addressed the weight loss of Resident#56 by recommending weekly weights. They stated the weights may have been inaccurate and brought this to the attention of the administrator. The dietician was told the facility had identified the inaccurate weights and were correcting it. On 05/03/24 at 11:50 a.m., RN #1 stated the DON, ADON or administration was responsible for reviewing recommendations made by the registered dietitian. They stated the recommendation was missed and the facility would…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-03 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure medications were securely stored for two (100/200 hall medication cart and 500/600 hall medication cart) of four medication carts observed. The DON identified four medication carts. Findings: On 04/30/24 at 12:57 p.m., the 500/600 hall medication cart was observed to be by the nurse's station, unlocked, and unattended. On 04/30/24 at 12:59 p.m., LPN #1 entered the nurse's station but had their back to the medication cart which remained unlocked and unattended. On 04/30/24 at 1:11 p.m., CMA #2 approached the medication cart and locked it before leaving it unattended. On 05/01/24 at 10:55 a.m., LPN #2 was observed to enter the room for Resident #36 to perform a fingerstick blood sugar check. LPN #2 was observed to leave the 100/200 hall medication cart unlocked and unattended. On 05/02/24 at 2:30 p.m., LPN #2 stated they were to secure medication carts before leaving them unattended. On 05/03/24 at 10:35 a.m., CMA #2 stated they were to make sure they locked the medication carts when they were unattended. On 05/03/24 at…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-03 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure food was served at a palatable temperature for one (noon meal) of one meal observed for palatability. The administrator identified 73 residents who received meals from the kitchen. Findings: On 04/29/24 at 10:38 a.m., Resident #69 stated their food was served cold to their room and at times the dietary department put their cold salad on the plates with hot food, which wilted the vegetables in the cold salad. On 05/01/24 at 1:30 p.m., during a resident group meeting, Resident #39 and Resident #41 stated they ate their meals in their rooms and their food was often served cold. On 05/01/24 at 12:15 p.m., the last tray on the back hall cart was provided to the survey team. The cornbread, broccoli with cheese, and potatoes were not observed to be served at a palatable temperature when tasted. On 05/03/24 at 4:45 p.m., the adminsitrator stated they had not received any complaints about cold food but would look into the concern.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure medication orders were implemented in a timely fashion for one (#1) of one resident reviewed for physician orders. The administrator reported the facility census was 73. Findings: Resident #1 had diagnoses which included unspecified psychosis and anxiety disorder. A significant change assessment, dated 12/12/23, documented Resident #1 was moderately impaired for daily decision making. A nurse note, dated 12/12/23 at 3:35 p.m., documented the physician had ordered Resident #1's olanzapine reduced from 10mg twice a day to 5mg at bedtime. A review of Resident #1's physician orders indicated the order for olanzapine 10mg twice a day was discontinued on 12/12/23. The physician orders further documented the order for olanzapine 5mg at bedtime was not entered until 12/15/23. On 01/08/24 at 9:00 a.m., the DON stated she received the order for olanzapine 5mg at bedtime on 12/12/23 but it was not started until 12/15/23.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-08 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure laboratory tests were completed per physician's orders for one (# 2) of five residents reviewed for laboratory services. The administrator reported the census was 73. Findings: Resident #2 had diagnoses which included diabetes mellitus and cerebral palsy. A quarterly assessment, dated 09/30/23, documented the resident was cognitively intact and required extensive physical assistance from staff. A physician order, dated 12/11/23, documented an A1c laboratory test was to be obtained on 12/11/23 and then every three months. A review of Resident #2's clinical record did not document an A1c was drawn on 12/11/23. A review of Resident #2's clinical record did not document the resident had refused any laboratory tests. On 01/04/24 at 2:23 p.m., the DON stated the ordered laboratory test had not been completed. They stated the order had been put in the lab computer system, but the lab company had not completed the order.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-27 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure assessments were coded accurately for four (#3, #19, #45, and #51) of four sampled residents whose assessments were reviewed for anticoagulant use. The DON identified nine residents who received anticoagulant medications. Findings: 1. Resident #3 had diagnoses which included atherosclerotic heart disease. The quarterly assessment, dated 12/26/22, documented the resident received an anticoagulant medication for seven of seven day during the look back period. Review of the December 2022 MAR did not reveal the resident had received an anticoagulant medication. 2. Resident #19 had diagnoses which included atherosclerotic heart disease. The quarterly assessment, dated 01/11/23, documented the resident received an anticoagulant medication for seven of seven days during the look back period. Review of the January 2023 MAR did not reveal the resident had received an anticoagulant medication. 3. Resident #45 had diagnoses which included transient cerebral ischemic attack (stroke). The quarterly assessment, dated 01/12/23,…

    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 · D2023-03-27 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 medication error rate of under 5% when the facility had two medication errors out of 25 opportunities resulting in an 8% medication error rate. The Director of Nursing identified 73 residents who received medications. Findings: On 03/23/23 at 1:00 p.m., LPN #1 failed to instruct Resident #226 to rinse their mouth after an Albuterol nebulizer treatment was administered. On 03/23/23 at 5:20 p.m., CMA #2 failed to instruct Resident #225 to wait one minute between puffs of their hand held inhaler of Breztri, and to rinse their mouth after the medication was administered. On 03/24/23 at 4:27 p.m., LPN #1 was asked what instruction was provided to the resident after the Albuterol was administered. They stated they did not know. They were asked to review the order. They stated they did not read all of the instruction for the medication. On 03/24/23 4:29 p.m., CMA #2 was asked what instruction should have been provided to the resident after the hand held inhaler was administered. They stated to wait between…

    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 · Dcited before2023-03-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to ensure medications were secured at all times for two of four medication carts observed. The Resident Census and Conditions of Residents form identified 73 residents resided at the facility. Findings: A facility Preparation and General Guidelines: Medication Administration-General Guidelines policy, revised 01/2018, read in part, .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by . On 03/21/23 at 2:49 p.m., the nurses cart outside room [ROOM NUMBER] was observed to be unlocked. The nurse was observed to enter the room and close the door. On 03/21/23 at 2:50 p.m., the DON was observed to roll by the unlocked cart and not lock it. On 03/21/23 at 2:51 p.m., 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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MGM HEALTHCARE — 27 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 4 of 52.3+1.7 vs chain
Health inspection 4 of 52.4+1.6 vs chain
Staffing 3 of 51.7+1.3 vs chain
Quality measures 4 of 53.6+0.4 vs chain
The other 26 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Arbor Hills Care & Rehab CenterFerguson, MO 1 of 5Bentwood Nursing & RehabFlorissant, MO 1 of 5Broadway Care & Rehab CenterMuskogee, OK 1 of 5Florissant Valley Health & Rehabilitation CenterFlorissant, MO 1 of 5Lansdowne VillageSaint Louis, MO 1 of 5Leisure Village Health Care CenterTulsa, OK 1 of 5Normandy Nursing CenterSaint Louis, MO 1 of 5Quarters At Des Peres, TheDes Peres, MO 1 of 5South Pointe Rehabilitation and Care CenterOklahoma City, OK 1 of 5Springfield Skilled Care CenterSpringfield, MO 1 of 5St Sophia Health & Rehabilitation CenterFlorissant, MO 2 of 5Eastgate Village Care & Rehab CenterMuskogee, OK 2 of 5Heritage Villa Care & Rehab CenterBartlesville, OK 2 of 5Sherbrooke VillageSaint Louis, MO 2 of 5Spring Valley Health & Rehabilitation CenterSpringfield, MO 2 of 5Sunset Health Care CenterUnion, MO 2 of 5Walnut Grove Care & Rehab CenterMcAlester, OK 3 of 5Forest Hills Care And Rehabilitation CenterBroken Arrow, OK 3 of 5Fort Gibson Care & Rehab CenterFort Gibson, OK 3 of 5Oak Park Care CenterSaint Louis, MO 4 of 5Cleveland Care And Rehab CenterCleveland, OK 4 of 5Jackson ManorJackson, MO 4 of 5Mitchell Care & Rehab CenterMcAlester, OK 4 of 5Rainbow Health Care Community And Rainbow AssistedBristow, OK 4 of 5Seminole Care And Rehabilitation CenterSeminole, OK 5 of 5Camelot Nursing And Rehabilitation CenterFarmington, MO

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
OK SNF HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 01/09/2024
OK SNF INVESTMENTS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 01/09/2024
JFB OK TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 01/09/2024
SOUTHEAST VENTURES TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST48%since 01/09/2024
HUDSON, JESSICAIndividualW-2 MANAGING EMPLOYEEsince 01/09/2024
FRIEDMAN, NAFTALIIndividualCORPORATE OFFICERsince 01/09/2024

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

Follow the money — this home’s finances

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

$6.5M
Net patient revenuemost recent cost report
+4.5%
Operating marginrevenue minus expenses
$849K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 12%Other / private 8%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $849K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$235per resident / day
operating cost
$7,140per month
≈ monthly operating cost
$246per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

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 375304. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, 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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