Drumright Nursing Home
701 N Bristow Ave, Drumright, OK 74030 · For profit - Limited Liability company · 133 certified beds · (918) 352-3249 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $102,356 in federal fines (most recent 2025-09-22)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (78%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.8% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.3% | 3.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 3.4% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.6% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 3.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 9.0% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.8% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 27.6% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.6% | 17.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.5% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 81.8% | 74.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.0% | 27.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.4% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.75 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.40 | 2.96 | 1.80 | worse |
* 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.
38.3% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 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 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.3%CMS range 27.8–51.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 8.2–18.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 70.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 46.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 4.6–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.24 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 133 beds and averages 54.4 residents a day — about 41% occupied, or roughly 79 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.40 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.23 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 3.84 hrs/resident/day on weekends vs 4.64 on weekdays — 17% thinner on weekends. RN hours go from 0.22 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 78% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 14 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · J2025-09-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
On 09/18/25, an IJ situation was determined to exist related to the facility's failure to protect residents from physical abuse.On 09/18/25 at 2:59 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 09/18/25 at 3:06 p.m., the administrator was informed of the existence of an IJ for abuse and the IJ template was provided.On 09/19/25 at 10:39 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Plan of RemovalResident #28 has been referred for inpatient geri-psych services. Until such time that the resident departs the facility, the resident was immediately placed on one-on-one supervision.All staff will receive inservice training regarding abuse prevention including resident to resident abuse. Specifically, staff will receive training to intervene when resident to resident abuse occurs, report abuse immediately to the Administrator, to assess or evaluate the resident who sustained abuse for injury and document those findings in the resident record. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2025-07-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 06/25/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent a resident with a cognitive deficit and a history of exit seeking behaviors from eloping from the facility. An order note, dated 03/08/25, showed Resident #1 tried to get out the front door. A quarterly resident assessment, dated 03/15/25, showed Resident #1's BIMS was 06 (severe cognitive impairment). A wander risk assessment, dated 04/12/25, showed Resident #1 was a high risk (score 15) for wandering. An incident note, dated 05/10/25 at 7:35 p.m., showed Resident #1 escaped the facility at approximately 7:00 p.m. Resident #1 made it one block down the road to Cimarron before worker realized they were gone. Staff assisted the resident into their car and drove the resident back to the facility. A care plan for the resident's elopement risk was not created until 05/12/25. A heath status note, dated 05/30/25, showed Resident #1 exhibited exit seeking behaviors. A combined…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-09-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to:a. prevent a fall during transportation for 1 (#2); andb. ensure interventions were initiated after a fall for 1 (#9) of 3 sampled residents reviewed for accidents.The DON identified 48 residents resided in the facility. Findings:An INCIDENT POLICY AND PROCEDURE policy, revised 03/31/23, read in part, The charge nurse will complete an incident report including all information known about the incident as well as immediate corrective measures implemented.1. Resident #2's admission resident assessment, dated 08/14/25, showed the resident had diagnoses which included severe protein-calorie malnutrition and adult failure to thrive. The assessment showed the resident's cognition was intact with a BIMS of 14. The assessment showed the resident was dependent on staff assistance for on activities of daily living and transfers. A hospital After Visit Summary, dated 09/11/25, showed Resident #2 had diagnoses which included fall, injury of head, and laceration of right lower extremity.A combined Initial and Final State Reportable…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · H2024-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident received treatment and monitoring of a newly developed pressure ulcer for one (#51), and provide treatment and services to prevent worsening of a pressure ulcer for one (#49) of three sampled residents reviewed for pressure ulcers. This resulted in worsening of both resident's pressure ulcers. The DON identified six residents with pressure ulcers. Findings: A facility POLICY AND PROCEDURE FOR THE PREVENTION AND TREATMENT OF PRESSURE ULCERS, revised 08/28/08, read in part, .Should a resident have an existing pressure ulcer or develop a pressure ulcer post admission, the facility will implement procedures to evaluate the ulcer regularly .The facility will evaluate the ulcer at least weekly, utilizing a flow sheet that notes the location of the ulcer, the stage, presence of eschar, size, color odor, drainage, tunneling/sinus tract/undermining if present .The facility will notify the physician upon the onset of the ulcer an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-22 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure PRN psychotropic medications were limited to 14 days for 2 (#9 and #28) of 5 sampled residents reviewed for unnecessary medication.The DON identified 48 residents resided in the facility. Findings: An undated facility policy titled Other drugs needing special handling and attention, read in part, Psychotropics drugs effective 11.28.17 PRN orders for psychotropic drugs are limited to 14 days, unless the physician believes that it is appropriate for the PRN to be extended beyond 14 days. The physician will document their rationale in the resident's medical record and indicate the duration of the PRN order. 1.Resident #9's physician's order, dated 07/25/25, showed lorazepam (antianxiety medication) 0.5 mg tablet. Give 0.5 mg by mouth every six hours as needed for anxiety related to dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #9's order for lorazepam had no stop date. An August 2025 MAR showed lorazepam was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-22 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — 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 resident's discharge assessment was transmitted for 1 (#24) of 12 sampled residents whose assessments were reviewed.The DON identified 48 residents resided in the facility. Findings:Resident #24's discharge assessment return not anticipated, dated 05/31/25, showed the resident had a planned discharge on [DATE].There was no documentation the discharge resident assessment was transmitted.On 09/22/25 at 10:03 a.m., the ADON stated the registered nurse was responsible for transmitting the completed resident assessments.On 09/22/25 at 10:06 a.m., the IP stated they tried to transmit resident assessments within five days of completion.On 09/22/25 at 10:09 a.m., the IP stated Resident #24's discharge assessment dated [DATE] was not transmitted.
- Potential for harm · Dcited before2025-09-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a nebulizer mask and tubing was stored in a manner to prevent cross contamination for 1 (#58) of 1 sampled resident reviewed for respiratory care.The DON identified 48 residents resided in the facility. Findings: On 09/15/25 at 12:42 p.m., a nebulizer mask was observed laying on Resident #58's nightstand.On 09/22/25 at 10:46 a.m., a nebulizer mask was observed laying on Resident #58's nightstand. The part of the tubing that connected to the machine was laying on the floor by the resident's bed.An undated facility policy titled POLICY AND PROCEDURE REGARDING CLEANING AND MAINTENANCE OF NEBULIZERS, OXYGEN SUPPLIES AND METERED DOSE INHALERS, read in part, when the equipment is not in use, it may be stored in a plastic container or covering.Resident #58's physician's order, dated 09/08/25, showed ipratropium-albuterol inhalation solution (a breathing treatment) 3mg/3ml, inhale one vial orally four times a day for wheezing.Resident #58's admission resident assessment, dated 09/12/25, showed the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-02 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident's care plan was updated to reflect each time the resident eloped from the facility for 1 (#1) of 3 sampled residents reviewed for elopement. The infection control nurse identified six residents at risk for elopement resided in the facility. Findings: A resident care plan policy, revised 03/27/17, read in part, The comprehensive care plan will be reviewed and updated by the IDT [interdisciplinary team] after each quarterly and annual assessment thereafter. A quarterly resident assessment, dated 03/15/25, showed Resident #1's BIMS was 06 (severe cognitive impairment). The assessment showed Resident #1 had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and psychotic disorder. An incident note, dated 05/10/25 at 7:35 p.m., showed Resident #1 escaped the facility at approximately 7:00 p.m. The note showed the resident made it down to Cimarron one block down the road before a worker realized they were gone. The note showed CNA #3 brought the resident back in their car and took the resident back…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-19 · tag F0610 — failed to investigate and act on abuse reports — patternRespond 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 conduct a thorough investigation after an allegation of abuse from staff for 2 (#1 and #2) of 3 sampled residents reviewed for abuse. The administrator identified 45 residents resided in the facility. Findings: A Policy and procedure regarding prohibition for resident abuse including corporal punishment, neglect and exploitation, revised 10/2022, read in part, Interviewing by standers, witnesses et. as soon as possible .Staff will increase supervision .and all other residents that may be impacted . All staff are required to report .OSDH, law enforcement and/or adult protective services. 1. Resident #1 had diagnoses which included major depressive disorder, schizoaffective, and paranoid disorder. Resident #1's quarterly resident assessment, dated 02/24/25, showed a BIMS score of 15, indicating the resident's cognition was intact. An OSDH initial incident report form, dated 03/09/25, did not show adult protective services was notified of the allegation. An attachment to the initial incident report, dated 03/09/25, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-09 · tag F0850 — failed to provide social-work services — widespreadHire a qualified full-time social worker in a facility with more than 120 beds.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure the individual functioning as the social worker met the required qualifications for a facility with more than 120 beds. The administrator identified 54 resident resided in the facility. Findings: An Oklahoma State Department of Health Nursing Facility License, issued on 11/07/22, documented the facility was licensed for a maximum of 133 beds. On 05/08/24 at 10:00 a.m., the ADON and DON were asked if they had a qualified social worker on a full time basis. They stated they did have a full time social worker and they would check on their qualifications. On 05/08/24 at 12:06 a.m., the DON stated their social worker had an associate in arts and had six years of experience as a case manager at a prison. They stated they did not have a bachelors degree. They stated they were licensed for 133 beds, but they did not have that many beds.
- Potential for harm · E2024-05-09 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a PRN psychotropic medication was limited to 14 days for one (#3) of five sampled residents reviewed for unnecessary medications. The DON identified five residents who had orders for PRN psychotropic medications. Findings: Res #3 had diagnoses which included anxiety and agitation. A physician order, dated 12/01/23, documented Ativan suspension (benzodiazepine medication) 1 mg/ml. Give 0.5 ml sublingually every fours hours as needed for 14 days. The February 2024 MAR document Ativan was administered on 02/26/24 and 02/28/24. The March 2024 MAR documented Ativan was administered on 03/03/24, 03/11/24, and 03/21/24. On 05/08/24 at 10:07 a.m., the ADON and DON were made aware of the resident's Ativan order. The ADON stated the order should have stopped and been reassessed. )
- Potential for harm · E2024-05-09 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure food was served at an appetizing temperature and palatable. The DM identified 52 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: 1. A quarterly resident assessment, dated 02/20/24, documented Res #5's cognition was intact. On 05/06/24 at 7:45 a.m., the resident was asked how was the food. They stated some of the food was not good. They stated they ate in their room and sometimes the food was cold. 2. A quarterly resident assessment, dated 04/29/24, documented Res #7 was moderately impaired in cognition. On 05/06/24 at 9:27 a.m., the resident stated the food was not good. They stated the food was cold all the time and sometimes it was so salty it would cross your eyes. They stated the facility would provide a sandwich as an alternative. They stated the biscuit served for breakfast was so hard they could not eat it. 3. A quarterly resident assessment, dated 04/28/24, documented Res #14's cognition was intact. On 05/06/24 at 8:17 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to prepare and serve food in a sanitary manner. The DM identified 52 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: An undated Spectrum Advance Hand Sanitizer Gel safety data sheet, read in part, .Flammable liquid and vapor .Keep away from heat/sparks/open flames/hot surfaces .Keep product and empty container away from heat and sources of ignition .Do not eat, drink or smoke when using this product . On 05/07/24 at 11:45 a.m., dietary aide #1 was observed preparing drinks for the lunch meal in the dining room. They entered the kitchen for a container of coffee, then returned to the dining room to prepare drinks. They did not wash their hands when entering the kitchen. Dietary aide #1 was observed entering the kitchen and preparing the coffee maker to make more coffee. They exited the kitchen and continued to prepare drinks for the meal. They did not wash their hands when entering the kitchen. Dietary aide #1 was observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to maintain an infection control program to help prevent the transmission of infections for two (#2 and #51) of three sampled residents reviewed for pressure ulcers. The DON identified six residents with pressure ulcers. Findings: An undated facility WOUND DRESSINGS policy, read in part, .Gather supplies: 3 or more pairs of Gloves; Wax paper; .Anything brought into the room must be cleaned or discarded .Place wax paper on a clean, dry surface next to where you will be working. Set up supplies on waxed paper . 1. Res #2 had diagnoses which included severe sepsis, need for assistance with personal care, pain, and personal history of other diseases of the musculoskeletal system and connective tissue. A physician order, dated 04/01/24, documented cleanse the area to the inner left foot with Betadine and cover with a protective dressing daily. On 05/08/24 at 9:40 a.m., LPN #2 was observed performing wound care for the resident. They gathered their supplies, placed them in a metal pan, and entered the resident's room.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2024-05-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — 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 resident's code status was accurate for one (#7) of one sampled resident reviewed for advance directives. The administrator identified 54 residents resided in the facility. Findings: Res #7 was admitted to the facility on [DATE] with diagnoses which included heart disease, COPD, presence of a pace maker, chronic pain, and CKD, A DNR consent form, dated [DATE], documented the resident gave consent for DNR. A physician order, dated [DATE], documented CPR. On [DATE] at 10:02 a.m., the ADON and DON were asked to verify the resident's code status. On [DATE] at 11:05 a.m., the ADON stated the resident had a DNR on file and they were supposed to be a DNR.
- Potential for harm · D2024-05-09 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 discharged from Part A skilled services, with benefit days remaining, was issued a SNF ABN and/or NOMNC notice for one (#53) of four sampled residents reviewed for beneficiary notices. The Beneficiary Notice worksheet identified eight residents were discharged from Part A skilled services with benefit days remaining in the past six months. Findings: Res #53 was admitted to the facilty for skilled services on 02/27/24 with diagnoses which included COPD, heart failure, CKD, type 2 diabetes mellitus, amputation of toes, and history of falling. An undated Benefit Eligibility Details report, documented as of 04/01/24 the resident had five days of skilled service remaining. Health status notes, dated 04/01/24, documented the resident's oxygen saturation dropped and the breathing treatment administered was ineffective. It was documented the nurse listened to the resident's lung sounds and wheezing was noted to the right lower lobe and the left lobe was diminished. It was documented the resident was sent out to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-09 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a discharged resident's clinical record contained a discharge summary for one (#54) of one sampled resident reviewed for facility initiated discharge. The administrator identified 54 residents resided in the facility. Findings: Res #54 had diagnoses which included COPD, heart failure, type 2 diabetes mellitus, panic disorder, and major depressive disorder. A physician order, dated 02/29/24, documented the resident was discharged home. There was no documentation a discharge summary was completed. On 05/07/24 at 11:07 a.m., the ADON was asked if a discharge summary had been completed for the resident. On 05/07/24 at 11:57 a.m., the ADON stated they had 30 days to complete a discharge summary and a discharge summary was not completed.
- Potential for harm · D2024-05-09 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 notify a resident and/or their representative of the resident's discharge in writing 30 days before the resident was discharged for one (#54) of one sampled resident reviewed for discharge. The administrator identified 54 residents resided in the facility. Findings: Res #54 was admitted to the facility on [DATE] with diagnoses which included COPD, heart failure, type 2 diabetes mellitus, panic disorder, and major depressive disorder. A social service note, dated 01/24/24, documented the resident had been denied nursing home Medicaid due to not sending in verification. It was documented the resident's family member was notified. A social service note, dated 02/22/24, documented the facility contacted DHS about the resident's long term care. It was documented the resident's case was still pending. A health status note, dated 02/29/24, documented the resident was discharged home. On 05/07/24 at 11:57 a.m., the ADON was asked the reason for the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-09 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
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 permitted to return to the facility after they were hospitalized for one (#53) of one sampled resident reviewed for hospitalization. The administrator identified 54 residents resided in the facility. Findings: An undated Notice of Bed Hold policy, read in part, .It will be the facility's policy that any resident who is transferred to a hospital for a period of less than five days will have the right to return and expect the bed and room which he/she resided at the time of his/her transfer .If a resident who is transferred with an expectation of returning to the facility cannot return to the facility, the resident will be discharged according to policy . Res #53 was admitted to the facilty for skilled services on 02/27/24 with diagnoses which included COPD, heart failure, CKD, type 2 diabetes mellitus, amputation of toes, and history of falling. Health status notes, dated 04/01/24, documented the resident's oxygen saturation dropped and the breathing treatment administered was ineffective. It was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-09 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to refer a resident with a newly evident or possible serious mental illness to the OHCA for a level II PASRR evaluation for one (#28) of two sampled residents reviewed for PASRR's. The administrator identified 54 residents resided in the facility. Findings: A level I PASRR, dated 06/27/23, documented Res #28 did not have evidence or diagnosis of a serious mental illness. On 07/28/23, the resident had a new diagnosis of bipolar type schizophrenia disorder. On 07/29/23, the resident had new diagnosis of borderline personality disorder and mood disorder due to known physiological condition with depressive features. There was no documentation the resident had been referred to the OHCA for a level II PASRR evaluation. On 05/08/24 at 10:04 a.m., the ADON and DON were made aware the resident had a negative level I pre-screen and was later identified with newly evident of possible serious mental illness. They were asked if the resident was referred to the OHCA for a level II PASRR evaluation. On 05/08/24 at 11:36 a.m., the ADON…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to include a care plan regarding dietary preferences for one (#28) of one sampled resident reviewed for care planning. The administrator identified 54 residents resided in the facility. Findings: Res #28 had diagnoses which included vitamin D deficiency and depression. A physician order, dated 04/01/24, documented the resident required a no added salt vegetarian diet. The order specified to make smoothies with super greens powder with meals as a supplement. On 05/07/24 at 9:24 a.m., the ADON stated the resident's food preferences should have been included in the care plan, but were not.
- Potential for harm · D2024-05-09 · tag F0729 — isolatedVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
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 verification from the nurse aide registry before allowing a CNA to work for two (CNA #4 and CNA #5) of 30 CNAs reviewed for certifications. The administrator identified 54 residents resided in the facility. Findings: 1. CNA #4's certification expired on [DATE]. A Time & Attendance - Employee Timecard documented CNA #4 worked on [DATE], [DATE], [DATE], and [DATE]. 2. CNA #5's certification expired on [DATE]. A Time & Attendance - Employee Timecard documented CNA #5 worked on [DATE], [DATE], and [DATE]. On [DATE] at 3:19 p.m., the ADON stated the IP nurse was responsible for ensuring the staff have current licenses and certifications. The IP was unavailable for interview.
- Potential for harm · D2024-05-09 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to follow the menu approved by the facility's dietitian for one of one meal service observed. The DM identified 52 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: The lunch menu for 05/07/24 documented residents were to have one pork chop, a half cup of broccoli rice casserole, six pieces of breaded squash, one dinner roll, chocolate cream desert, and a beverage of choice. The chocolate cream desert was marked out and devil cake was written in its place. On 05/07/24 at 11:00 a.m., a tour of the kitchen was conducted. Two pans of meatloaf were observed being removed from the oven. On 05/07/24 at 11:10 a.m., the DM stated they did not have enough pork chops for all of the residents. They stated the menu was changed to meatloaf. The DM stated the facility dietitian was not notified of the changes. The DM stated the administrator made changes as needed.
- Potential for harm · Dcited before2024-05-09 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure the QAA committee met at least quarterly. The administrator identified 54 residents resided in the facility. Findings: There was no documentation the QAA committee met October 2023 through December 2023. On 05/07/23 at 9:33 a.m., the DON was asked to provide documentation the QAA committee met October 2023 through December 2023. On 05/07/23 at 10:37 a.m., the DON stated there was no documentation the QAA committee met during the quarter of October 2023 through December 2023. They stated the QAA committee meets quarterly and they should have met that quarter.
- Potential for harm · D2024-05-09 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 offer an influenza vaccine for one (#15) of five sampled residents reviewed for vaccinations. The administrator identified 54 residents resided in the facility. Findings: Res #15 was admitted to the facility on [DATE]. A vaccination record review documented the resident had not received an influenza vaccine. On 05/09/24 at 12:16 p.m., the IP stated there was a vaccination clinic for the residents at the end of 2023. They stated they had not offered vaccinations to the residents who admitted after the clinic.
- Potential for harm · Ecited before2023-03-30 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility's Quality Assurance and Process Improvement committee failed to meet at least quarterly to identify and address performance improvement issues. The Resident Census and Conditions of Residents form, dated 03/27/23, documented 42 residents resided in the facility. Findings: On 03/27/23 at 11:12 a.m., the Administrator reported the QA Committee had not been meeting since he became the facility Administrator in October of 2022. The Administrator reported he had a new DON and several other new staff members who had replaced previous department leaders. On 03/29/23 at 2:30 p.m., the facility QAPI policy and procedure was reviewed. Committee meeting notes documented the last QA/QAPI committee meeting had been on 09/29/22. On 03/29/23 at 3:10 p.m., the DON and ADON reported staff had stand-up meetings every morning to discuss falls and any other issues that might have occurred since the previous day. The DON and ADON reported the facility did a fall assessment after each fall but they had not been having any kind of interdisciplinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-30 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 the COVID-19 vaccine was offered, education provided, and a COVID-19 vaccine consent/refusal was signed by the residents or resident representatives for two (#7 and #36) of five residents reviewed for compliance with COVID-19 vaccinations The Resident Census and Conditions of Residents, dated 03/27/23, documented 42 residents resided in the facility. Findings: The Policy Regarding Resident/Client COVID-19 Vaccinations, dated 11/29/21, read in parts, .It shall be the policy of the facility to offer each resident/client the opportunity to receive the COVID-19 vaccination .Each resident/client will have the right to accept or refuse the vaccination .Each individual or resident/client representative as authorized, will receive information regarding the COVID-19 vaccination .Administration as applicable, benefits and potential side effects of the vaccine, and a CDC Fact Sheet regarding signs and symptoms of COVID-19, ways to prevent the spread and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure a comprehensive care plan was developed for pressure ulcers and hospice services for one (#2) of one resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents form, dated 03/27/23, documented 42 resident resided in the facility. Findings: Resident #2 had diagnoses which included major depressive disorder, cerebral infarction, coronary artery disease, and Schizophrenia. The resident's Care Plan, dated 12/22/22, documented no focus areas related to pressure ulcers or hospice services. An Annual MDS Assessment for resident #2, dated 12/23/22, documented the resident's cognition was severly impaired. Physician Orders for resident #2 read in parts, .Admit to Traditions Hospice effective 12/22/21 for coronary artery disease .12/15/22 float heels while in bed. every shift for Pressure relief .Traditions Hospice to evaluate for readmit to hospice services 1/24/23 01/30/23 Lantiseptic Skin Protectant External Ointment 50 % apply to bilateral buttocks topically every shift for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to assess and intervene in a timely manner, when a fall with injury was not reported immediately, for one (#1) of two residents reviewed for falls with major injury. The facility reported two residents had experienced falls with major injury in the past 12 months. Findings: The DON reported there was no facility policy related to falls or reporting of falls and/or incidents. Resident #1 had diagnoses which included heart failure, intellectual disabilities, anxiety, and Cerebral Palsy. A Fall Risk Evaluation for resident #1, dated 11/15/22, documented the resident had experienced no falls in the past three months, was ambulatory, had normal gait/balance, and took 1 to 2 medications which might contribute to falls. The resident had a score of 10 or above which represented a high risk for falls. A Progress Note/Incident Note, dated 12/15/22 at 5:36 p.m., documented in parts, .Late entry .This nurse was not notified of fall until the next day, according to the CNA and ACMA who were on duty that evening .this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-30 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 routine laboratory values (blood work) were obtained to adequately monitor medications for one (#5) of five residents reviewed for unnecessary medication. The Resident Census and Conditions of Residents form, dated 03/27/23, documented 42 residents resided in the facility. Findings: Resident #5 was admitted with diagnoses which included diabetes mellitus. A Quarterly MDS Assessment for resident #5, dated 01/02/23, documented the resident's cognition was intact. A Care Plan for resident #5, dated 01/11/23, read in parts, .At risk for hypo/hyperglycemia due to diabetes mellitus and takes insulin daily .Will continue to received Humalog/Trulicity injections as directed by the physician .Will have FSBS checked as directed by the physician and prn for any s/s of hypo/hyperglycemia . A Pharmacist's Consult to Physician for resident #5, dated 02/01/23, read in parts, .Please review the resident's labwork for the following meds to insure that the lab values are within the recommended values and that the labwork has been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-30 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure therapeutic diets were prepared for residents per physician orders for one (#32) of three residents reviewed for food preparation. The Resident Census and Conditions of Residents form, dated 03/27/23, documented 12 residents received mechanically altered diets. Findings: Resident #32 was admitted to the facility on [DATE]. The resident's diagnoses included dysphagia. The facility's Food Preparation policy, not dated, read in parts, .Mechanical Food Preparation - Use a food processor to mechanically alter the food to the desired texture (ground or minced) .Pureed Food Preparation - Use a food processor to puree foods to maintain appropriate texture and nutritive value .Pureed foods should be prepared to the consistency and thickness of mashed potatoes rather than a gravy or watery texture . A diet order for resident #32, dated 01/04/22, documented the diet texture to be ground meat with gravy, puree other solids, and no bread for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$102,356 in federal fines across 3 penalties.
- $38,909 — penalty dated 2025-09-22
- $23,095 — penalty dated 2025-07-02
- $40,352 — penalty dated 2024-05-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to OKLAHOMA NURSING HOMES, LTD. — 7 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.6 | -1.6 vs chain |
| Health inspection | 1 of 5 | 2.9 | -1.9 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 1 of 5 | 2.6 | -1.6 vs chain |
The other 6 homes this chain runs (chain average 2.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANDRA CHEEK FARMER TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 8% | since 01/01/2005 |
| STEVEN R. TUBBS REVOCABLE TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF | 14% | since 01/01/2025 |
| CHEEK, BARNIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 8% | since 01/11/2005 |
| ESTEP, PATSY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 01/11/2005 |
| HASKINS, LLOYD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 01/11/2005 |
| MCGREW, JUSTIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 6% | since 01/01/2025 |
| CAROLYN D LEAVERTON REVOCABLE TRUST | Organization | TRUSTEE OF THE SNF | — | since 01/01/2025 |
CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375466. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-22, 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.