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Lakeview Nursing & Rehab

607 Woodland Avenue, Eufaula, OK 74432 · For profit - Corporation · 70 certified beds · (918) 618-9588 Medicare & Medicaid certified

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Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
213 N Broadway St · (918) 410-0200 · Call to confirm hours
Pharmacy
800 Forest Ave · (918) 689-2547 · Call to confirm hours
Grocery
200 S 2nd St · (918) 689-5211 · Call to confirm hours
Park
Golding St · (918) 689-2534 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 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 improved from 2 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.9%13.6%15.4%worse
Long-stay residents who lose too much weight2.0%3.3%5.4%better
Long-stay residents with a catheter left in their bladder4.0%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.8%2.0%better
Long-stay residents with depressive symptoms0.5%3.4%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury8.5%4.7%3.3%worse
Long-stay residents whose ability to walk worsened14.3%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.6%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine94.8%94.6%95.3%typical
Long-stay residents with pressure ulcers1.1%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control27.1%17.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table65.6%17.5%17.1%check this — see note marked dagger below the table
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents rehospitalized after admission20.8%27.3%22.6%typical
Short-stay residents with an outpatient ER visit16.3%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.872.311.67worse
Long-stay outpatient ER visits per 1,000 resident days3.052.961.80worse

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.

11.2%U.S. median 10.7%
Went back to hospital
0.07U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.07 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.5–17.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.8%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 worsened4.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.601.02Oct 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

0.18
RN hours/ resident / day
1.07
LPN hours/ resident / day
2.47
Aide hours/ resident / day
3.72
Total nurse hours/ resident / day
0.18
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 70 beds and averages 51.3 residents a day — about 73% occupied, or roughly 19 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.18 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 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 3.54 hrs/resident/day on weekends vs 3.79 on weekdays — 7% thinner on weekends. RN hours go from 0.17 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

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

3
deficiencies at the latest standard inspection (2025-02-13)
2
at the previous standard inspection (2023-10-24)

Deficiencies are more than at the previous inspection — worsening. 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.

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

  • Immediate jeopardy · K2022-07-07 · 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 On 07/06/22 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent falls and to consistently identify and implement interventions to prevent falls for Res #15, 24, and #30. Resident #15 fell multiple times including one where the Res had sustained a laceration to the right leg which required sutures and subsequently became infected and required further hospitalization. Res #24 fell multiple times and with one fall received a large bump to the upper right forehead and was later found face down in the floor of another resident's room. Res #24 was not responsive and subsequently sent to the hospital for evaluation. Res #24 continued to fall. Res #30 had fallen multiple times with different injuries including one where the Res had sustained a hematoma to his right eyebrow. A week later Res #30 was sent to the hospital for evaluation of seizure like activity. On return from the hospital, Res #30 continued to fall. On 07/06/22 at 2:10 p.m., OSDH…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 the deep fryer was clean and free of food particles and the splash guard on side of stove was cleaned routinely. The administrator identified 55 residents resided in facility and received their food from the kitchen. Findings: A Sanitization policy, revised October 2008, read in part, the food service area shall be maintained in a clean and sanitary manner, and for fixed equipment, the removable components will be scraped to remove food particle accumulation. On 02/10/25 at 10:20 a.m., a tour of the kitchen was conducted. The deep fryer was dirty with dried food particles and there was an accumulation of grease on the splash guard attached to the stove. On 02/11/25 at 8:53 a.m., a tour of the kitchen was conducted. The deep fryer was dirty with dried food particles and there was an accumulation of grease on the splash guard attached to the stove. On 02/11/25 at 8:56 a.m., dietary aide #1 was asked when was the deep fryer and the side of the stove cleaned. They stated they thought the food was from last…

    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 · D2025-02-13 · 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

    Based on record review and interview, the facility failed to ensure a referral to the LOCEU was made when a resident had a diagnosis of a serious mental illness for one (#30) of 2 sampled residents reviewed for PASARR. The administrator identified 55 residents who resided in the facility. Findings: Resident #30 had diagnoses which included schizoaffective disorder and anxiety disorder. A PASARR form, dated 03/03/22, showed the resident did not have a diagnosis of a serious mental illness. The care plan, dated 09/24/24, showed the resident received psychotropic medication. An annual assessment, dated 12/20/24, showed the resident had a psychiatric/mood disorder. The assessment showed the resident was not currently considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. On 02/11/25 at 3:06 p.m., MDS/PASARR coordinator #1 stated the level l was correct, but with a new diagnosis of schizoaffective disorder a level ll referral should have been made.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure an insulin vial was cleaned prior to administration for 1 (#27) of 1 sampled resident observed for insulin administration. The assistant director of nursing identified four residents received insulin. Findings: A Specific Medication Administration policy, dated April 2018, showed staff were to clean the stopper and the top of the vial, with an alcohol pad, and allow it to air dry. On 02/11/25 at 10:42 a.m., LPN #1 was observed to prepare an insulin injection for Resident #27. They did not clean the top of the insulin vial prior to drawing up the insulin. On 02/11/25 at 10:44 a.m., LPN #1 administered the insulin to Resident #27. On 02/11/25 at 10:47 a.m., LPN #1 stated they were supposed to clean the top of the insulin vial but, forgot.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 record review, observation, and interview, the facility failed to prepare and distribute food under sanitary conditions. The Resident Census and Conditions of Residents report documented 38 residents resided in the facility. Findings: A policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices documented .Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens .Employees must wash their hands: .After handling soiled equipment or utensils .During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks .After engaging in other activities that contaminate the hands . On 10/17/23 at 12:08 p.m., Dietary Aide #1 was assisting with preparation of the cart for the hall. A lid covering a meal plate fell off the cart to the floor. The aide picked up the lid and returned it to cover the plate. On 10/17/23 at 12:13 p.m., Dietary [NAME] #1 was observed in the kitchen serving the noon meal. The cook had a beard that…

    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 · D2023-10-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to assist a resident with ADLs for one (#18) of 12 residents reviewed for activities of daily living. The Resident Census and Conditions of Residents report documented 38 residents resided in the facility. Findings: A policy titled Safe Lifting and Movement of Residents documented .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary . Res #18 was admitted to the facility on [DATE] with diagnoses which included Huntington's disease, anxiety disorder, and major depressive disorder. A quarterly assessment, dated 09/07/23, documented the resident was moderately impaired for daily decision making and required extensive to total assistance with ADLs. The care plan, last reviewed on 09/07/23, documented the resident required assistance with…

    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 · E2022-07-07 · tag F0578 — failed to honor advance directives / code status — pattern
    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 2. Res #42 was admitted to the facility with diagnoses which included diabetes mellitus and hypertension. A history and physical note, dated [DATE], documented in part, .Code status: DNR/no CPR . Physician progress notes, dated [DATE], [DATE], [DATE], [DATE], and [DATE], read in parts, .Code status: Do not attempt Resuscitation (DNR/No CPR) . On [DATE] at 9:45 a.m., Res #42's chart was observed with a sticker on the spine of the chart that read DNR. A review of Res #42's medical records revealed no DNR document was in the chart. On [DATE] at 2:13 p.m., the administrator stated a signed DNR form should have been in the medical records. The administrator reported Res #42 would have to be a full code until a DNR document could be obtained. Based on record review, observation, and interview, the facility failed to ensure accurate documentation of residents' code status for two (#30 and #42) of two residents reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 50 residents…

    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 · E2022-07-07 · tag F0582 — pattern
    Give 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 provide letters of NOMNC and/or ABN for two (#12 and #21) of three residents reviewed Beneficiary Notices. The Beneficiary Notice - Residents discharged Within the Last Six Months, documented 20 residents were discharged from Medicare covered Part A stay with benefit days remaining in the last six months. Findings: 1. The ''SNF Beneficiary Protection Notification Review form, documented Res #21 was admitted to Part A skilled services on 01/25/22, discharged from Part A skilled services on 02/19/22, and remained in the facility. The facility did not provide Res #21 with a NOMNC or ABN letter. 2. The ''SNF Beneficiary Protection Notification Review form, documented Res #12 was admitted to Part A skilled services on 05/07/22, discharged from Part A skilled services on 05/17/22, and remained in the facility. The facility did not provide Res #12 with an ABN letter. On 07/05/22 at 4:23 p.m., the administrator stated the discharge for Res #21 occurred in February and a corporate nurse was responsible for completing and providing…

    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 · E2022-07-07 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 three (#24, 30, and #42) of four residents whose PASRR documents were reviewed. The administrator reported 35 residents who resided in the facility required a Level II PASRR. Findings: 1. Res #42 was admitted to the facility with diagnoses which included mood disorder and depression. A review of the resident's medical records revealed no PASRR level I was documented. On 07/07/22 at 8:48 a.m., the administrator provided a PASRR, dated 07/06/22. The administrator stated the PASRR for Res #42 had not been done upon admit. The administrator stated the PASRR was done on 07/06/22 and should have been done upon admission. 2. Res #24 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance and psychotic disorders. A PASRR level I report, dated 12/04/2020, did not indicate the resident had a serious mental illness. A quarterly assessment, dated 05/18/22, documented the resident was severely impaired with…

    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 · E2022-07-07 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed develop a comprehensive care plan which included goals and interventions for three (#15, 30 and #35) of 21 residents whose care plans were reviewed. The facility failed to develop a care plan related to: a. the use of a urinary catheter for Res #15. b. pressure ulcers for Res #30. c. bathing needs for Res #35. The Resident Census and Conditions of Residents documented 50 residents resided in the facility. Findings: 1. Res #15 had diagnoses which included osteoarthritis, embolism of deep veins of the lower extremities, pulmonary embolism, and morbid obesity. A care plan for Res #15, dated 04/14/22, documented Res #15 had occasional urinary incontinence and would have no further decline in urinary continence through the next review period. A quarterly assessment, dated 05/11/22, documented Res #15 had a urinary catheter. On 06/29/22 at 9:19 a.m., Res #15 stated she received a urinary catheter when was in the hospital in April and the facility had not attempted to remove it. Res #15 stated she did not know why she…

    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 · E2022-07-07 · 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, observation, and interview, the facility failed to update resident care plans to accurately address the residents' current needs for four (#15, 21, 24, 30, and #40) of 21 residents whose records were reviewed. The facility failed to update resident care plan related to: a. falls for resident #15, 21, 24, and #30. b. code status and use of hypnotic medications for Res #40. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: 1. Res #15 had diagnoses which included osteoarthritis, embolism of deep veins of the lower extremities, pulmonary embolism, and morbid obesity. A care plan, dated 12/03/20, documented Res #15 was at risk for falls. The plan of care did not document a goal or interventions to prevent falls. An incident report, dated 07/22/21, documented Res #15 had attempted to transfer from bed to BSC and appeared to have lost her balance. The report documented Res #15 hit her head on the bathroom door and sustained a small…

    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 11 citations
  • Potential for harm · E2022-07-07 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure the consultant pharmacist recommendations were acted on for two (#24 and #40) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included acute cystitis with hematuria, unspecified dementia with behavioral disturbance, and psychotic disorder. A MRR, dated 11/29/21, documented the pharmacist requested a reduction for Risperdal (an antipsychotic medication). The review was not signed by the physician or dated. On 07/07/22 at 11:44 p.m., The IP stated the MRR for 11/29/21 was not addressed and there is no record to indicate if or when the physician received the MRR. 2. Res #40 had diagnoses which included insomnia, bipolar disorder, PTSD, and depression. A MRR, dated 07/26/21, requested an end date or medical justification for as needed Vistaril (an antianxiety medication). There was no physician response documented. A MRR, dated 09/27/21, requested an end date or medical…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-07 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to monitor for target behaviors and side effects and failed to act on a MRR request for reduction for one (#15) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 50 resident resided in the facility. Findings: Res #15 had diagnoses which included major depressive disorder and generalized anxiety disorder. The current care plan documented Res #15 experienced feeling down, depressed, or hopeless. The care plan documented the staff were to monitor the target behaviors for Res #15. A quarterly assessment, dated 05/11/22, documented the resident was moderately to severely depressed and received antidepressant medications seven days of the seven day assessment period. On 05/25/22, following a hospitalization, the physician ordered the following medications: Airpiprazole 5 mg daily for depression, Mirtazapine 30 mg daily at bedtime for depression, and Zoloft 50 mg daily for depression, On 07/05/22, Res #15's clinical records were reviewed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-07 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, it was determined the facility failed to ensure the removal of expired medications and supplies from the medication storage room. This had the potential to affect all 50 residents who resided in the facility. Findings: On 07/07/22 at 11:00 a.m., the medication room was observed. Expired medications and supplies were found in the facility's medication storage room for the following: One bottle of Control Solution for blood glucose monitoring with an expiration date of 06/05/22. Two boxes of 12 gauge flip lock needles with an expiration date of 06/2020. Two boxes of albuterol sulfate solution 2.5mg/3ml with a use by date of 11/10/2021. On 07/07/22 at 11:00 a.m., the CMA reported the expired medications and supplies should have been removed from the medication storage room.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-07 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to complete a significant change assessment after a resident decline for one (#12) of 21 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents documented 50 residents resided in the facility. Findings: Res #12 had diagnoses which included metabolic encephalopathy, depression, schizophrenia, and chronic obstructive pulmonary disease. A quarterly assessment, dated 02/07/22, documented the resident was moderately impaired in cognition; was independent in bed mobility and transfers; required supervision for eating; and required extensive assistance with toileting. A quarterly assessment, dated 05/13/22, documented the resident was severely cognitively impaired, was total assist with bed mobility, eating, and toileting, and no longer transferred. A physician progress note, dated 05/17/22, documented Res #12 had been placed on skilled services due to a recent hospitalization. On 07/07/22, at 10:00 a.m., the MDS coordinator stated the resident had declined after the hospitalization and a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-07 · tag F0640 — isolated
    Encode 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 transmit resident assessments to the CMS system within 14 days of completion for one (#2) of two residents reviewed for resident assessments. The Resident Census and Conditions of Residents documented 50 residents resided in the facility. Findings: Resident #2 admitted to the facility on [DATE]. An admission assessment, dated 02/23/22, was not transmitted to CMS until 04/07/22. On 07/07/22, at 10:00 a.m., the MDS coordinator stated assessments should be transmitted within 14 days, but it was missed.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure a resident with urinary incontinence did not continue to have a urinary catheter after a hospitalization without a clinical condition which documented a catheter was necessary for one (#15) of one resident reviewed for catheterization. The Resident Census and Conditions of Residents report documented four residents had indwelling urinary catheters. Findings: Res #15 had diagnoses which included chronic kidney disease and morbid obesity. A quarterly assessment, dated 02/14/22, documented Res #15 was frequently incontinent of urine. A care plan, dated 04/12/22, documented Res #15 had occasional urinary incontinence with a goal of having no further decline in urinary incontinence through the review period. A quarterly assessment, dated 05/11/22, documented Res #15 had an indwelling urinary catheter. On 06/29/22 at 9:19 a.m., Res #15 was observed in her bed. She stated when she was in the hospital she received a urinary catheter. Res #15 stated the facility had not attempted to remove the catheter and she…

    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 · D2022-07-07 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to assess and monitor for pain every shift according to the plan of care for one (#26) of one resident reviewed for pain. The Resident Census and Conditions of Residents form documented 27 residents on a pain management program. Findings: Res #26 was admitted to the facility with diagnoses which included chronic pain and cervical disc displacement. A policy and procedure, labeled Pain-Clinical Protocol, read in parts, .Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .The staff will reassess the individuals pain . A physician order, dated 06/15/21, documented Norco 5/325mg every eight hours PRN for pain. A physician order, dated 06/21/21, documented refer to spine surgeon with chronic neck and back pain. A physician order, dated 02/10/22, documented the facility was to order an MRI of the spine. A care plan, dated 02/14/22, documented the resident had intermittent episodes of mild pain. The interventions documented to monitor 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-07 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure an assessment for risk of entrapment was conducted and an informed consent and physician order was obtained prior to installing side rails for one (#30) of four resident reviewed for accident hazards. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: Res #30 had diagnoses which included dementia with behavioral disturbance, bladder cancer, and diabetes. A significant change resident assessment, dated 05/23/22, documented the resident was severely cognitively impaired; required extensive assistance with bed mobility; required total assistance with transfers, toileting, and personal hygiene; and had one fall without injury since last assessment. On 07/05/22 at 2:34 p.m., Res #30 was observed in bed with an air mattress and half side rails in the up position on both sides of the head of the bed. The resident's medical chart was reviewed and no documentation of a physician order, assessment, or consent for bed rail use was found. On 07/06/22 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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, observation, and interview, the facility failed to reduce a medication which had been identified by the pharmacist consultant as appropriate for reduction and the physician agreed for one (#15) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report documented 50 residents resided in the facility. Findings: Res #15 had diagnoses which included GERD. A consultant pharmacist MRR, dated 10/27/21, asked if the physician would consider a reduction in pantoprazole (a medication used to treat GERD). Resident #15's physician agreed to the request. Res #15's clinical record did not document the dose of pantoprazole had been reduced. A quarterly assessment, dated 05/11/22, documented the resident required set up and supervision with eating. A physician order for readmission from a hospitalization, dated 05/25/22, documented the facility was to give the resident pantoprazole 40 mg tablet by mouth once daily. On 07/06/22 at 9:06 a.m., the ADON was asked if the medication had ever been reduced. She stated she would…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-07 · 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 and interview, the facility failed to ensure meals from the kitchen were prepared, served, and stored, in a sanitary manner for 50 of 50 residents who received their meals from the kitchen. Findings: On 06/29/22 from 6:04 a.m. through 6:45 a.m., observations of the kitchen were made. The DM had an open can of soft drink, which she was drinking from, and kept it on the food prep counter. The freezer had a bag of onion rings which were open to air and the bottom of the freezer had peas and carrots which had spilled and were loose in the bottom. The cook was observed to place her can of soft drink on to the prep counter where she was preparing biscuits. An unidentified DA was observed doing dishes. The DA wiped the counter then used a large spoon and stirred a pot of rice on the stove without first washing their hands. The DA then proceeded to make tea without washing their hands. On 06/30/22 at 1:35 p.m., during a subsequent observation of the kitchen, a DA was observed with their face mask down while pouring a glass of milk for a resident. The DA was then…

    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 · D2022-07-07 · tag F0909 — failed to maintain a comfortable temperature — isolated
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, observation, and interview, the facility failed to conduct regular inspections of beds, side rails, and mattresses, to identify any areas of potential entrapment for one (#30) of four residents reviewed for accident hazards. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: Res #30's physician order, dated 03/18/22, documented low air loss mattress related to the deep tissue injuries. On 07/05/22 at 2:34 p.m. Res #30's bed was observed with an air mattress and half side rails in the up position on both sides of the head of the bed. On 07/06/22, at 3:30 p.m., maintenance staff stated routine inspections of the beds are not conducted and there was not a written log of bed inspections. He stated new equipment delivered from contract or ancillary companies was not inspected after installation and Res #30's bed had not been inspected after delivery. On 07/07/22 at 5:00 p.m., the administrator stated she was unaware of the requirements for bedrails.

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to BRADFORD MONTGOMERY — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.2+1.8 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 2 of 52.4-0.4 vs chain
Quality measures 2 of 52.9-0.9 vs chain
The other 10 homes this chain runs (chain average 2.2★, 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
MONTGOMERY, BRADFORDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/16/2018
CHOCKPOYAH, SERETTAIndividualW-2 MANAGING EMPLOYEEsince 01/23/2019

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
+7.2%
Operating marginrevenue minus expenses
$215K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 92%Medicare 4%Other / private 4%

About 92% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $215K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$202per resident / day
operating cost
$6,146per month
≈ monthly operating cost
$218per 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 375575. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-13, 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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