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Fairview Fellowship Home For Senior Citizens, Inc

605 East State Road, Fairview, OK 73737 · Non profit - Corporation · 100 certified beds · (580) 227-3783 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0605) — most recent Nov 20251 immediate-jeopardy citation$18,415 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $18,415 in federal fines (most recent 2025-05-23)
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1084 Nickerson St · (580) 824-2291 · Call to confirm hours
Pharmacy
210 E State Rd · (580) 227-2045 · Call to confirm hours
Grocery
820 E State Rd · (580) 227-3731 · Call to confirm hours
Park
Gloss Mountain State Park Fairview Oklahoma · Typically dawn to dusk
Place of worship
811 E Elm St · (580) 227-4769

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 3 of 5
Short-stay residentsrehab / post-hospital 1 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.

Overall rating1★
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 increased12.8%13.6%15.4%better
Long-stay residents who lose too much weight4.3%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.5%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.9%2.8%2.0%worse
Long-stay residents with depressive symptoms3.6%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 injury8.1%4.7%3.3%worse
Long-stay residents whose ability to walk worsened12.9%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication36.4%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine92.4%94.6%95.3%typical
Long-stay residents with pressure ulcers3.7%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control23.1%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table20.1%17.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.1%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine76.2%74.1%79.4%typical
Long-stay hospitalizations per 1,000 resident days1.432.311.67better
Long-stay outpatient ER visits per 1,000 resident days3.172.961.80worse

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.

42.9% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.9%U.S. median 51.5%
Got home and stayed home
12.0%U.S. median 10.7%
Went back to hospital
31.8%U.S. median 56.6%
Met the expected recovery
0.11U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 31.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 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 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% 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 SNF42.9%CMS range 32.9–54.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.0%CMS range 8.1–18.210.7%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 discharge31.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge45.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge40.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 stay3.2%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 worsened9.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 4.1–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

0.20
RN hours/ resident / day
0.93
LPN hours/ resident / day
3.54
Aide hours/ resident / day
4.67
Total nurse hours/ resident / day
0.15
RN hoursweekends
52.9%
Total nursing turnover
71.4%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 69.4 residents a day — about 69% occupied, or roughly 31 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 4.67 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 3.54 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 4.39 hrs/resident/day on weekends vs 4.78 on weekdays — 8% 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 53% is about the same as 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

1
deficiencies at the latest standard inspection (2025-12-04)
11
at the previous standard inspection (2024-05-23)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Immediate jeopardy · K2025-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 05/22/25 at 1:40 p.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to provide adequate supervision to prevent elopement from the facility. 1. Resident #1's admission record, dated 11/01/24, showed the resident was admitted with diagnoses which included unspecified dementia and displaced intertrochanteric fracture of the left femur. A Wander risk assessment, dated 11/01/24, showed Resident #1 was a low risk for elopement with a score of 4. A care plan, last revised 05/08/25, showed the resident was exit seeking on the following dates; a. 03/19/25; b. 04/11/25; c. 04/15/25; d. 04/07/25; e. 04/08/25; and f. 05/03/25. The care plan, revised 05/08/25, showed Resident #1 was moved to the memory care unit on 05/08/25. There were no additional documented interventions to address the wandering and exit seeking other than redirection. Resident #1's progress notes showed exit seeking behaviors and attempts 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were used during wound and catheter care for 2 (#18 and #34) of 2 sampled residents reviewed for enhanced barrier precautions practices by staff. The administrator identified six residents required enhanced barrier precautions during the provision of care. Findings: A facility policy titled Enhanced Barrier Precautions Policy and Procedure, last updated on 07/28/25, read in part, Enhanced barrier precautions expand the use of PPE and refer to the use of gowns and gloves during high-contact resident care activities.Examples of high-contact resident care activities requiring gown and glove use include dressing, providing hygiene, changing briefs, device care, urinary catheter care, feeding tube, wound care with any skin opening requiring a treatment order. 1. On 12/04/25 at 8:36 a.m., LPN #1 was observed performing donning gloves to provide wound care on Resident #34's left lower leg. After wound care LPN…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-21 · tag F0757 — failed to avoid unnecessary drugs — pattern
    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 observation, record review, and interview, the facility failed to ensure medication orders for a psychotropic medication were correct to prevent unnecessary medication administered after a gradual dose reduction for 1 (#8) of 3 sampled residents reviewed for unnecessary medications. The DON identified 72 residents were administered medications from the facility. Findings:A facility policy titled PCU059-Medication Discrepancies and Adverse Reactions, dated 03/2025, read in part, Medication Discrepancy: An inappropriate or incorrect medication prescribed for, dispensed for, or given to a resident. It is also an omission of an ordered medication due to a prescribing, dispensing, or administering error.On 10/13/25 at 1:36 p.m., Resident #8 was observed ambulating independently in the common area on the memory care unit. Resident #8's admission record, dated 08/30/24, showed they were admitted with diagnoses which included unspecified dementia and generalized anxiety disorder.Resident #8's quarterly MDS assessment, dated 09/11/25, showed their cognition was severely impaired…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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 observation, record review, and interview, the facility failed to ensure a medication order for an anti-anxiety medication was entered accurately and an anti-anxiety medication was administered following physician orders for 1 (#8) of 3 sampled residents reviewed for medication administration.The DON identified 72 residents received medications from the facility. Findings:On 10/13/25 at 1:36 p.m., Resident #8 was observed ambulating independently in the common area on the memory care unit. Resident #8's admission record, dated 08/30/24, showed they were admitted with diagnoses which included unspecified dementia and generalized anxiety disorder.Resident #8's quarterly MDS assessment, dated 09/11/25, showed their cognition was severely impaired with BIMS score of 04. The assessment showed Resident #8 was prescribed anti-anxiety medication during the look back period. A facility policy titled PCU059-Medication Discrepancies and Adverse Reactions, dated 03/2025, read in part, Medication Discrepancy: An inappropriate or incorrect medication prescribed for, dispensed for, or…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 professional accepted standards of quality were met related to a physician's order being entered accurately for 1 (#8) of 3 sampled residents reviewed for unnecessary medications.The DON identified 72 residents were administered medications from the facility. Findings:The facility's policy titled PCU059-Medication Discrepancies and Adverse Reactions, dated 03/2025, read in part, Medication Discrepancy: An inappropriate or incorrect medication prescribed for, dispensed for, or given to a resident. It is also an omission of an ordered medication due to a prescribing, dispensing, or administering error.On 10/13/25 at 1:36 p.m., Resident #8 was observed ambulating independently in the common area on the memory care unit. Resident #8's admission record, dated 08/30/24, showed they were admitted with diagnoses which included unspecified dementia and generalized anxiety disorder.Resident #8's quarterly MDS assessment, dated 09/11/25, showed their cognition was severely impaired with BIMS score of 04. The assessment showed…

    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 · Ecited before2025-05-23 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure careplan's were reviewed or revised for 2 (#1 and #6) of 3 sampled residents reviewed for care plan revisions. The DON identified 75 residents resided in the facility. Findings: The facility's policy titled Resident Safety- Wandering/Elopement, revised 10/2023, read in part, The director of nursing will evaluate each resident upon admission and every three months thereafter for need of the wonder dash guard system. The evaluation will utilize information input from the family or legal guardian of the resident, the resident physician, and when possible, the resident. Additionally, residents will be evaluated for the wonder guard system when they: Seem confused or disoriented Pack belongings Have a history of wondering Verbalize a desire to leave Attempt to leave the facility Residents who are mobile enough to wonder and exhibit one or more of the above behaviors will be recommended for wonder guard. The facility's policy titled MDS (minimum data…

    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 · E2024-05-23 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents dependent for meal assistance were treated with dignity during the noon meal for five (#11, 12, 16, 36, 50, 57, and #58) of 13 dependent residents observed during meal assist The MDS coordinator stated 13 residents required assistance with meal intake Findings: 1. Resident #11 had a diagnosis of seizures. A Care Plan, dated 11/27/23, documented Resident #11 had a potential impaired nutritional status and required assistance with meals at times. A Quarterly Assessment, dated 02/29/24, documented Resident #11 was cognitively intact for decision making and independent with eating. 2. Resident #12 had a diagnosis of dementia. A Care Plan, dated 07/20/23, documented Resident #12 had a potential for impaired nutritional status and required assistance with meals at times. A Quarterly Assessment, dated 04/18/24, documented Resident #12 had severe cognitive impairment and required partial to moderate assistance with eating. 3. Resident #36 had a diagnosis of dementia. A Care Plan, dated 11/30/20,…

    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 · Ecited before2024-05-23 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure the care plan was updated with fall interventions after falls for two (#32 and #36) of four sampled residents reviewed for falls. The DON identified 50 residents had falls in the facility and 65 residents who resided in the facility. Findings: The facilty's Incident Reporting, Information Routing and Follow-Up policy, revised 03/2023, read in part, All incidents are to be reported .so that proper care , interventions, treatment is identified and performed. The policy also read, The Care Plan Coordinator will review for appropriate interventions listed, update the care plan. A MDS and Care Plan Process document, revised 07/2023 read in part, Each care plan is to be accurate in identifying individualized approaches from each discipline to assist in providing care to each resident. The facility's Policy #13 policy, revised 07/2023, read in part, .If a resident is identified at risk for falls the MDS/ Care Plan coordinator will be notified and it will be addressed in the care plan . 1. Resident #32 had…

    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 · E2024-05-23 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents were offered hydration for one (#44) of two sampled residents reviewed for hydration. The MDS coordinator identified 13 residents who required assisted with eating/drinking. Findings: Resident #44 had diagnoses which included dementia, urinary incontinence, and UTI. A dietary note, dated 3/11/24, documented annual nutrition assessment was completed and Resident #44 had the estimated need of 1802 milliliters of fluid, monitor, and to continue the plan of care. A physician's progress note, dated 05/08/24, documented Resident #44 had an abnormal CT which indicated possible old stroke, Resident #44 had a UTI and to continue antibiotics for five days, culture pending, push fluids, and monitor. Resident #44's electronic record documented the resident had 600 ml of fluid on 05/09/24, 720 ml on 05/10/24, 360 ml on 05/11/24 and 05/12/24, 600 ml on 05/13/24 and 05/14/24, 1190 ml on 05/15/24, 360 ml on 05/16/24 and 05/17/24, 480 ml on 05/18/24, and 680 ml on 05/19/24. On 05/19/24 at 10:35 a.m., Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0700 — pattern
    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 observation, record review, and interview, the facility failed to ensure bed rails were assessed for risk of entrapment, reviewed the risks and benefits of the bed rails with the resident or resident representative, or obtained informed consent prior to installation of the bedrail for two (#43 and #168) of two sampled residents assessed for accident hazards. The DON identified 23 residents who utilized bed rails. Findings: 1. Resident #43 had diagnoses which included dementia, history of right femur, and protein calorie malnutrition. Resident #43's significant change assessment, dated 03/19/24, documented they had severe cognitive impairment and required partial to substantial assistance with ADL care. An ADL care plan, dated 01/04/24, documented Resident #43 required extensive assistance with ADLs and utilized half bed rails. On 05/19/24 at 12:49 p.m., Resident # 43 had a half bedrail in place on their bed in the upright position. 2. Resident #168 had diagnoses which included heart failure, altered mental status, and non-displaced chip fracture of the right talus. (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-23 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours a day, seven days a week. Census: 65 The PBJ Staffing Data Report, for 10/01/23 thru 12/31/23, documented the facility did not identify RN hours for 10/1/23, 12/22/23, 12/25/23, and 12/30/23 On 05/21/24 at 9:15 a.m., requested HR to provide documentation an RN had worked eight consecutive hours, in the building on 10/1/23, 12/22/23, 12/25/23, and 12/30/23. On 05/21/24 at 1:40 p.m., HR reported the facility did not have RN coverage in the building on 10/01/23.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2024-05-23 · 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 — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to provide a separately locked, permanently affixed compartment for storage of controlled drugs for one of two refrigerators utilized for storage of drugs. The DON identified 65 residents who resided in the facility. Findings: On 05/21/24 at 3:20 p.m., the medication mini refrigerator was observed at the nurse's station on hall five. The medication refrigerator was sitting on the counter not permanently affixed and there was a small metal lock box inside the refrigerator not affixed. The lock box was observed with LPN #2. The lock box contained two plastic bags with the following medication: Lorazepam 0. 5mg 30 syringes and Lorazepam 0. 5mg 22 syringes. The nurses' station where the mini refrigerator was observed had an open window area to the hall. On 05/22/24 at 10:02 a.m., the nurse's station on hall five was observed with the door propped open, the black mini fridge was observed on the counter not affixed. On 05/22/24 at 10:05 a.m., RN #2 stated the door was closed and locked most of the time. On 05/23/24 at 1:38 p.m., the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0851 — pattern
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure the Payroll Based Journal accurately reflected RN coverage. Census: 65 Findings: The PBJ Staffing Data Report, for 10/01/23 thru 12/31/23, documented the facility did not identify RN hours for 10/1/23, 12/22/23, 12/25/23, and 12/30/23 On 05/21/24 at 9:15 a.m., requested HR to provide documentation an RN had worked in the building on 10/1/23, 12/22/23, 12/25/23, and 12/30/23. On 05/21/24 at 1:40 p.m., HR provided documentation RN coverage for the facility on 12/22/23, 12/25/23 and 12/30/23. They stated the PBJ report not did not accurately reflect the RN coverage on three of the four days in question.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews, the facility failed to ensure: a. hand hygiene was maintained during eating assistance for seven (#11, 36, 55, 56, 57, 58, and #64) of 15 sampled residents observed during noon meal assistance on the secure unit; b. enhanced barrier precautions were implemented for a resident with an indwelling catheter and the urinary catheter bag was not on the floor for one (#12) of one sampled resident reviewed for infection control with a catheter; and c. oxygen tubing and humidification bottles were labeled for one (#34) of one sampled residents reviewed for the use of oxygen equipment. Census: 65 Findings: A Hand Washing Policy, updated on 03/15/11, read in parts, .Hands should be thoroughly washed before and after providing resident care .hand washing techniques must be followed at all times . The facilty's Evaluation for Justification of Indwelling Catheter Use policy, dated 10/2023, read in part, .STEPS TO PREVENT INFECTIONS IN CATHETER RESIDENTS .Catheter should never touch the floor, neither tubing or bag . 1. On 05/20/24 at 11:19…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents were administered the pneumonia vaccination for two (#12 and #49) of five sampled residents reviewed for immunizations. The administrator identified 65 residents who resided in the facility. Findings: The facility's undated Immunizations and Vaccinations policy, read in part, .Pneumonococcal [sic]vaccines will be offered between Oct and March each year The policy also documented, The puemonococcal [sic] vaccine will be offered every five .years unless otherwise specified by the primary physician. 1. Resident #12 had diagnoses which included dementia. A document titled, Vaccine Information, dated 07/19/23, documented the resident's representative gave permission for the resident to receive the pneumonia vaccine. There was no documentation in the resident's record the pneumococcal vaccine had been administered. 2. Resident #49 had diagnoses which included pneumonia and diabetes. A document titled, Vaccine Information, dated 09/29/23, documented the resident gave permission to receive the pneumonia vaccine.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    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 interview and record review, the facility failed to ensure OHCA was notified after a resident received a significant mental health diagnosis for two (#12 and #30) of five residents reviewed for Pasarr. The DON identified 56 residents had mental health diagnosis. Findings: 1. Resident #12 was admitted on [DATE] with diagnosis which included vascular dementia with mood disturbance and anxiety. A comprehensive assessment dated [DATE] documented Resident #12's cognition was severly impaired and had Anxiety disorder in section I Active Diagnoses. A quarterly assessment, dated 10/19/23 documented anxiety,depression, and psychotic disorder in section I Active Diagnoses. A Order Summary Report, dated 5/23/24, read in part, .Celexa Oral Tablet 10 mg .related to depression .9/18/23 .Seroquel Oral Tablet 25 MG---related to unspecified psychosis not due to a substance or known physiological condition . 9/27/23 On 05/22/24 at 01:43 p.m., the DON Tell me about the Seroquel prescribed 9/28/23. The DON stated 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to develop a care plan for the use of bed rails for one (#168) of two sampled residents who had bed rails. The DON identified 23 residents who had bed rails. Findings: The facility's MDS and Care Plan Process policy, revised 07/2023, read in part, The plan of care is a road map in how to best care for each resident and the needs each individual resident has. The policy also read, Each care plan is to be accurate in identifying individualized approaches .to assist in providing care to each resident. Resident #168's care plan was reviewed. The care plan did not document the use of bed rails. On 05/22/24 at 12:54 p.m., Resident #168 was observed laying on their side in bed with half bed rails observed in the upright position. On 05/22/24 at 1:53 p.m., Resident #168 observed in bed there were two half rails on bed in the upright position. On 05/22/24 at 2:07 p.m., the DON stated Resident #168 used bed rails for independence and repositioning. They stated they did not find the use of bed rails documented on the care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-06 · tag F0604 — failed to not use physical restraints improperly — pattern
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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: A. conduct an assessment of the resident for use of resident alarms, B. document the medical symptom being treated for the use of resident alarms, C. document ongoing re-evaluation for the need of resident alarms for three (#2, 53, and #109) and D. obtain a physician order for a floor pressure alarm for one (#109), E. obtain a physician order for a personal alarm for one (#2) and F. care plan the use of resident alarms for one (#109) of four sampled residents reviewed for resident alarms. The DON identified 13 residents with alarms resided in the facility. Findings: 1. Resident #109 had diagnoses which included dementia and mood disturbance. A Nurses note, dated 02/22/23 at 2:38 p.m., documented the resident had arrived at the facility and walked with a walker with the assistance of one staff member and gait belt short distances only. It documented otherwise the resident used a wheelchair. A Nurses note, dated 02/22/23 at 6:15 p.m., documented Resident #109 was confused , tried numerous times to stand alone…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-06 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and observation the facility failed to ensure resident assessments were accurate for three (#11, 25, and #28 ) of 14 sampled residents reviewed for accuracy of assessments. The Resident Census and Condition of Residents form, dated 04/05/23, documented 59 residents resided in the facility. Findings: A Long-Term Care Facility Resident Assessment document, dated October 2019, read in part, .Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin) .Do not code antiplatelet medications such as aspirin . 1. Resident #25 had diagnoses which included hypertension and hyperlipidemia. A Physician Order, start date 10/14/20, documented the resident was to receive aspirin 81 mg once daily for heart health. A Quarterly Resident Assessment, dated 03/02/23, documented the resident received an anticoagulant seven of the last seven days (02/24/23, 02/25/23, 02/26/23, 02/27/23, 02/28/23, 03/01/23, and 03/02/23). On 04/06/23 at 1:53 p.m., MDS Coordinator #2 was asked to explain how they coded medications on the MDS Resident Assessments. They stated…

    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 · Ecited before2023-04-06 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure an RN worked a minimum of eight hours a day, seven days a week for eight of eight days reviewed. The Resident Census and Conditions of Residents report, dated 04/05/23, documented 59 residents resided in the facility. Findings: The fiscal year quarter one PBJ Staffing Data report, dated 04/03/23, documented no RN hours for the following dates: 10/12/22, 10/15/22, 10/16/22, 10/22/22, 11/05/22, 11/20/22, 12/13/22, and 12/26/22. On 04/05/23 at 9:04 a.m., during the Entrance Conference, the DON was provided a copy of the above PBJ Staffing report. The DON was asked to provide documentation an RN worked at least eight hours on 10/12/22, 10/15/22, 10/16/22, 10/22/22, 11/05/22, 11/20/22, 12/13/22, and 12/26/22. On 04/06/23 at 8:09 a.m., the DON stated We did not have RN coverage. She was asked the policy for RN coverage. She stated she was not sure the facility had a written policy, but they had to have RN coverage for Eight hours, seven days a week.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-06 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a Resident Assessment was completed on admission for one (#109) of 14 sampled residents reviewed for Resident Assessments. MDS Coordinator #1 identified three newly admitted residents in the last 30 days resided in the facility. Findings: Resident #109 had diagnoses which included dementia, arthritis, and hypertension. An admission Resident Assessment, dated 03/02/23, showed a status of in progress. An Order Summary report, dated 04/06/23, documented Resident #109's admission date was 02/22/23. On 04/06/23 at 8:43 a.m., MDS Coordinator #1 was asked what the policy was for completing MDS Resident Assessments. They stated admission assessments were completed within 14 days. MDS Coordinator #1 was asked to review Resident #109's admission Resident Assessment and explain the status in progress. They stated, It was somehow missed. They stated they weren't sure how it got missed. They stated it was completed now and was waiting to be signed.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-06 · 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 elected hospice services for one (#53) of one sampled resident reviewed for hospice services. The Resident Census and Conditions of Residents report, dated 04/05/23, documented 7 residents received hospice care. Findings: A Resident Assessment Instrument policy, revised October 2019, read in parts .The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule and/or in accordance with the Resident Assessment Manual .When there has been a significant change in the resident's condition . Resident #53 had diagnoses which included dementia with behaviors, depression, and anxiety. An admission Assessment, dated 01/26/23, documented Resident #53 was not receiving hospice services. A Physician Order, dated 01/18/23, documented Resident #53 admitted to hospice services. No significant change resident assessment was completed when Resident #53 started…

    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

“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

$18,415 in federal fines across 1 penalty.

  • $18,415 — penalty dated 2025-05-23

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
DYKES, LUCILLE MARIEIndividualW-2 MANAGING EMPLOYEEsince 06/11/2012
KLIEWER, CLAYIndividualCORPORATE OFFICERsince 03/27/2012

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

Net patient revenuemost recent cost report
Operating marginrevenue minus expenses

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.

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 375427. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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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