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Linwood Village Nursing & Retirement Apts

530 South Linwood Avenue, Cushing, OK 74023 · For profit - Limited Liability company · 67 certified beds · (918) 225-2220 Medicare & Medicaid certified

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Flagged for abuseResident-funds citation (F0565)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent May 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (59%) 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
600 S Linwood Ave · (918) 725-1599 · Call to confirm hours
Pharmacy
200 S Highland Ave · (918) 225-5200 · Call to confirm hours
Grocery
822 E 2nd St
Park
1000 S Highland Ave · (918) 225-0277 · Typically dawn to dusk
Place of worship
302 S Linwood Ave · (918) 225-5638

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.2%13.6%15.4%worse
Long-stay residents who lose too much weight3.1%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 infection2.2%2.8%2.0%worse
Long-stay residents with depressive symptoms0.0%3.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.3%4.7%3.3%worse
Long-stay residents whose ability to walk worsened21.4%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.5%25.7%18.9%typical
Long-stay residents given the seasonal flu vaccine93.9%94.6%95.3%typical
Long-stay residents with pressure ulcers2.7%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control26.1%17.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table2.9%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication2.5%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine29.6%74.1%79.4%worse
Short-stay residents rehospitalized after admission24.6%27.3%22.6%typical
Short-stay residents with an outpatient ER visit7.9%16.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.712.311.67typical
Long-stay outpatient ER visits per 1,000 resident days1.382.961.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

49.0% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.0%U.S. median 51.5%
Got home and stayed home
14.1%U.S. median 10.7%
Went back to hospital
36.8%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 36.8% 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 38 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 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.0%CMS range 40.0–61.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.1%CMS range 9.2–20.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge36.8%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 discharge34.2%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 discharge15.8%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 hospitalization8.0%CMS range 4.2–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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

0.23
RN hours/ resident / day
0.61
LPN hours/ resident / day
2.67
Aide hours/ resident / day
3.51
Total nurse hours/ resident / day
0.25
RN hoursweekends
58.6%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 67 beds and averages 48.6 residents a day — about 73% occupied, or roughly 18 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.67 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 3.16 hrs/resident/day on weekends vs 3.65 on weekdays — 13% thinner on weekends. RN hours go from 0.22 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-05-23)
9
at the previous standard inspection (2024-02-23)

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.

18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.

  • Potential for harm · E2025-05-23 · tag F0655 — pattern
    Create 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 ensure baseline care plans were completed within 48 hours of admission for 3 (#47, 54, and #161) of 15 sampled residents reviewed for baseline care plans. The administrator identified 55 residents resided in the facility. Findings: A Care Plans- Baseline policy, revised March 2022, read in part, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social Services; and f. PASARR recommendation, if applicable. 1. An undated admission Record, showed Resident #47 was admitted to the facility on [DATE]. There was no baseline care plan completed within 48 hours…

    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 · E2025-05-23 · tag F0851 — pattern
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the direct care staffing hours on the Quality of Care report were accurately reported. The administrator identified 55 residents resided in the facility. Findings: A policy titled Quality of Care (QOC) Reporting policy, read in part, This policy establishes a structured approach to tracking, reporting, and improving Quality of Care in SNF's, (Skilled nursing facility) ensuring compliance with CMS (Centers for Medicaid/Medicare) regulations, PDPM (payment driven patient module) documentation standards, and Quality Reporting Programs (QRP). Review of the Quality of Care Report for February, March, and April 2025, showed the following days were below the state required minimum of 2.9%: a. 02/02/25 = census 57, total direct care hours were 161.78= 2.8%, b. 02/09/25 = census 60, total direct care hours were 159.06= 2.6%, c. 02/15/25 = census 60, total direct care hours were 156.77=2.6%, d. 02/16/25 = census 60, total direct care hours were 155.53=2.5%, e. 02/22/25 = census 60, total direct care hours were 150.29=2.5%, f.…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — 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 a resident's DNR was valid for 1 (#212) of 15 sampled residents reviewed for advance directives. The administrator identified 55 residents resided in the facility. Findings: An Advance Directives policy, revised [DATE], read in part, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives .Advance Directive is a written instruction, such as a living will or durable power of attorney .Durable Power of Attorney for Health Care' a document that delegates authority to a legal representative to make health care decisions in case the individual delegating that authority subsequently becomes incapacitated .Do Not Resuscitate (DNR)- indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other…

    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 · D2025-05-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a resident was free from abuse for 1 (#162) of 2 sampled residents reviewed for abuse. The administrator identified 55 residents resided in the facility. Findings: A policy titled Abuse,Neglect and Exploitation, dated 01/01/25, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.The facility will make efforts to ensure all residents are protection from physical and psychosocial harm. An initial OSDH Incident Report Form, for the incident date 02/07/25 Part B, read in part, [Resident #162] told the shower aids, late Friday afternoon, that in the night [they] had asked the aide for ice water and [they] threw a cup of water in [their] face. No injuries were noted. [Resident #162] has been a resident since 12/27/24 on skilled services. [Resident #162] had a slip and fall accident in November 2024 which has left [them] with partial paralysis.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a thorough investigation was completed for an allegation of abuse for 1(#162) of 2 sampled residents reviewed for abuse. The administrator identified 55 residents resided in the facility. Findings: A policy titled Abuse,Neglect and Exploitation, dated 01/01/25, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.The facility will make efforts to ensure all residents are protection from physical and psychosocial harm. An initial OSDH Incident Report Form, for the incident on 02/07/25 Part B, read in part, Resident #162] told the shower aids, late Friday afternoon, that in the night [Resident #162] had asked the aide for ice water and [Resident #162] threw a cup of water in [CNA #1] face. No injuries were noted. [Resident #162] has been a resident since 12/27/24 on skilled services. [Resident #162] had a slip and fall accident in November 2024…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure 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 ensure dented cans, and opened bottles were removed from circulation in the dry storage. The administrator identified 55 residents resided in the facility and ate from the kitchen. Findings: On 05/20/25 at 9:53 a.m., two 2.6 pound cans of hot dog chili sauce, and a can of tuna were observed to have dents along the seals. A plastic bottle of red food dye had torn foil covering the opening, leaving the bottle open to air. The date of receival written on the cans was 02/25. A policy Food Receiving and Storage, revised November 2022, read in part, Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. On 05/20/25 at 10:03 a.m., the DM stated the staff had dropped the chili cans, so the dietician told them they could serve the chili since they knew when the damage occurred. The DM stated he did not notice the can of tuna was bent or that the foil did not secure the bottle of food coloring. On 05/23/25 at 11:20 a.m., the dietician stated if…

    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 · D2025-05-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a water management plan to prevent waterborne pathogens had been implemented. The administrator reported 55 residents resided at the facility. Findings: A facility policy titled Water Management Program, implemented 09/08/23, read in part, It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards .Documentation of all the activities related to the water management program shall be maintained in the water management program binder for a minimum of three years. On 05/23/25 at 10:31 a.m., the DON, regional administrator, and maintenance director were unable to provide documentation of any measures to prevent growth of Legionella. The maintenance director stated they did not really know about Legionella prevention.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure abuse training on hire was conducted for 1 (CNA #2) of 3 staff members files who's employee files reviewed. The administrator identified 55 residents resided in the facility. Findings: The employee file for CNA #2 showed a hire date of 01/28/25. There was no abuse training on hire located in the employee file. On 05/23/25 at 9:40 a.m., the regional administrator stated the BOM had pulled the file and CNA #2 had not completed the actual training in the computer software system used. They stated staff was given fourteen days to complete the training's and CNA #2 never turned it in.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-23 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Administrator identified 49 residents resided in the facility. Findings: A Resident Council Meeting policy, dated 01/02/24, documented the facility shall act upon concerns, make attempts to accommodate, and communicate their decisions to the council. Resident Council minutes, dated 11/30/23, documented concerns with nurses yelling down the hall, medications were administrated late, call lights in the morning not being answered while food was being delivered, residents not being assisted timely, hamburgers were dry, not enough vegetables, and resident items were missing. Resident Council minutes, dated 12/28/23, documented continued problems with medications, food, and missing items. There was no documentation concerns were acted upon or a response was provided to the council. On 02/22/24 at 1:57 p.m., a resident meeting was conducted with six residents in attendance. Residents stated staff don't…

    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 · E2024-02-23 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans were revised for three (#34, 40, and #32) of 13 sampled residents reviewed for care plans. The Administrator identified 49 residents resided in the facility. Findings: A Fall Prevention Program policy, dated 01/02/24, documented the plan of care would be revised as needed. 1. Resident #34 had diagnoses which included dementia. A Care Plan for falls, was last updated 01/09/24. Progress Notes, dated 02/07/24 and 02/10/24, documented the resident fell. It documented on 02/07/24 Resident #34 sustained a right clavicle fracture. It documented no injuries sustained from fall on 02/10/24. Risk Management notes, dated 02/07/24 and 02/10/24 documented Resident #34 returned from the hospital on [DATE] with no treatment recommended. It documented a medication adjustment was completed related to fall on 02/10/24. The care plan did not reflect any changes related to falls. On 02/23/24 at 10:02 a.m., the DON stated staff should be revising the care…

    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
Show the remaining 8 citations
  • Potential for harm · E2024-02-23 · 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 and interview, the facility failed to ensure: a. fall interventions were care planned after falls and have a process for notifying staff of interventions for one (#34), b. fall interventions were implemented and care planned after falls for one (#40), and c. a fall assessment was completed for one (#32) of three sampled residents reviewed for falls. The Administrator identified 49 residents resided in the facility. Findings: A Fall Risk Assessment policy, dated 01/02/24, documented the assessment will be completed when a significant change was identified. It documented the care plan will be completed for each resident to identify each item on the risk assessment and will be updated accordingly. It documented to monitor the effectiveness of the care plan interventions and modify the interventions as necessary. 1. Resident #34 had diagnoses which included dementia. A Care Plan for falls, was last updated 01/09/24. Progress Notes, dated 02/07/24 and 02/10/24, documented the resident fell. It…

    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 · D2024-02-23 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect 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 staff investigated reports of misappropriation of resident items for one (#1) of one sampled resident for misappropriation of property. The Administrator identified 49 residents resided in the facility. Findings: An Abuse policy, dated 01/02/24, documented misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings without the resident's consent. It documented investigating different types of violations. It documented taking all necessary actions as a result of the investigation, which may include, but not limited to: analyzing occurrences, to determine why misappropriation of resident property occurred, and what changes were needed to prevent further occurrences; define how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstrate of staff competency after training implemented; identification of staff responsible for implementation 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#40) of one sampled resident reviewed for PASRR. The Administrator reported 49 residents resided in the facility. Findings: Res #40 was readmitted to the facility on [DATE] with a new diagnosis of psychotic disorder with delusions. The resident's record contained no documentation the facility contacted OHCA with the new diagnoses. On 02/23/24 at 11:17 a.m., MDS coordinator #1 reported state was not notified of the new mental health diagnosis.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — 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 a comprehensive care plan was developed for psychotic disorder with delusions for one (#40) of 13 sampled residents whose care plans were reviewed. The Administrator reported 49 residents resided in the facility. Findings: Res #40 was readmitted to the facility on [DATE] with a diagnosis of psychotic disorder with delusions. A care plan, dated 01/29/24, contained no documentation the resident had a diagnosis of psychotic disorders with delusions and did not include goals or interventions. On 02/23/24 at 11:03 a.m., the DON reported the psychotic disorder should have been care planned.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#51) of two sampled residents reviewed for discharge. The Administrator identified 49 residents resided in the facility. Findings: A Discharge Summary policy, dated 01/02/24, documented upon discharge of a resident, other than emergency discharge or death, a discharge summary will be provided that should include: a. recapitulation of the resident's stay, b. final summary of the resident's status, c. reconciliation of all pre-discharge medications, and d. a post-discharge plan of care. Resident #51 had diagnoses which included wedge compression fracture of the fourth lumbar vertebra. A Nurse Progress Note, dated 11/24/23, documented Resident #51 discharged from the facility. On 02/23/24 at 9:56 a.m., the DON stated the discharge nurse completed the discharge summary. She stated if she saw the discharge summary had not been completed, then she would complete it. On 02/23/24 at 9:59 a.m., the DON stated the discharge summary for Resident #51 hadn't been completed.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a resident's specialist appointment was completed timely for one (#34) of one sampled resident reviewed for social services. The Administrator identified 49 residents resided in the facility. Findings: A Social Services policy, dated 01/02/24, documented the social worker or designee would pursue the provision of any identified need which may include making referrals and obtaining needed services from outside entities. Resident #34 had diagnoses which included dementia. An Incident Note, dated 02/07/24 documented Resident #34 fell and was sent to a local hospital. A Nurse Progress Note, dated 02/07/24, documented the nurse from the hospital called and stated Resident #34 had a fractured right collar bone and needed to follow up with an orthopedic surgeon to determine if it needed a repair. It documented the DON was notified. There was no documentation Resident #34 had followed up with an orthopedic surgeon. On 02/23/24 at 10:02 a.m., the DON stated Resident #34 was suppose to see someone after the resident sustained…

    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 · D2024-02-23 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure influenza and pneumococcal vaccinations were offered for one (#104) of five sampled residents reviewed for immunizations. The Administrator identified 49 residents resided in the facility. Findings: A Pneumococcal Vaccine (Series) policy, undated, read in parts, .Each resident will be assessed for pneumococcal immunization upon admission .Each resident will be offered a pneumococcal immunization . An Influenza Vaccination policy, undated, read in part, .Influenza vaccinations will be routinely offered annually from October 1st through March 31st . Resident #104 had diagnoses that included dementia. Resident #104's immunization record did not document the resident, nor their representative, had been offered or received an influenza or pneumonia immunization. On 02/23/24 at 11:38 a.m., the DON was asked if residents were offered influenza and pneumonia vaccines on admission. They stated not really. The DON acknowledged neither Resident #104 or their representative were informed of the availability of the vaccines nor…

    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 · D2024-02-20 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure two trash dumpster's were covered. The Daily Census, dated 02/09/24, documented 52 residents resided in the facility. Findings: A Disposal of Garbage policy, dated 01/02/24, documented containers and dumpster's were to be kept covered when not being used. On 02/09/24 at 10:16 a.m., two outside trash dumpster's were observed. Both dumpster's were observed to have an open lid. One black glove, one black sock, two clumps of paper towels, plastic spoons and forks were observed around the dumpster's. On 02/09/24 at 10:26 a.m., the Administrator stated the dumpster's were suppose to be closed after staff took out the trash.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
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 SKYBLUE HEALTHCARE — 12 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 2 of 52.1-0.1 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 3 of 53.3-0.3 vs chain
The other 11 homes this chain runs (chain average 2.1★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
RIVERS EDGE OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/06/2023
RIVERS EDGE PARTNERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 10/01/2023
OELBAUM, YITZCHOKIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL15%since 01/06/2023
BRADLEY, SAMANTHAIndividualW-2 MANAGING EMPLOYEEsince 02/22/2023
GANZ, DAVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 10/01/2023

CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$4.0M
Net patient revenuemost recent cost report
-2.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 63%Medicare 6%Other / private 31%

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

$233per resident / day
operating cost
$7,074per month
≈ monthly operating cost
$228per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.

Typical monthly cost in Oklahoma
$7,026/mo
Nursing home (semi-private)
$7,756/mo
Nursing home (private)
$6,150/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375471. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-23, 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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