Heavener Nursing & Rehab
114 West 2nd Street, Heavener, OK 74937 · For profit - Limited Liability company · 84 certified beds · (918) 653-2464 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 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 held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.3% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.0% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 10.7% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 3.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.4% | 4.7% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.8% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 37.5% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 14.8% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 14.4% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.4% | 17.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.5% | 74.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 35.3% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.3% | 16.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.14 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.61 | 2.96 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.6% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 18.5% 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 27 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.6%CMS range 41.7–63.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 8.2–16.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 18.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 11.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 18.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 12.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 3.7–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.38 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 84 beds and averages 71.5 residents a day — about 85% occupied, or roughly 12 beds typically open. It runs fairly full. 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 3.59 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 2.83 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 3.06 hrs/resident/day on weekends vs 3.80 on weekdays — 19% thinner on weekends. RN hours go from 0.16 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
35 citations, most serious first. The 13 most serious are shown; the remaining 22 are one tap away and print in full.
- Immediate jeopardy · J2022-11-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
On 11/07/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the physician provided laboratory orders for routine monitoring for Res #63 who received Warfarin/Coumadin (an anticoagulant medication used as a blood thinner). On 11/07/22 at 4:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 11/07/22 at 4:45 p.m., the Regional Manager was notified of the IJ situation. On 11/08/22 at 11:30 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated 11/07/22, read in part: Plan of Removal Anticoagulant Therapy: Immediate Actions: 1. Review of facility records identified 3 residents on Coumadin therapy with identified resident #63 out to hospital. 2. Inservice started for Nursing staff regarding the following: a. Coumadin (Anticoagulant therapy Clinical Protocol P&P) b. Lab requirements for anticoagulant therapy to include routine draws of PT/INR c. Ensuring Physician [sic] orders are obtained 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.
- Immediate jeopardy · Jcited before2022-11-08 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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
On 11/07/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the pharmacist conducted a MRR (Medication Regime Review) specific to Warfarin/Coumadin (a blood thinner) and lab monitoring from 03/03/22 to 10/26/22 for Res #63 who received Warfarin. On 11/07/22 at 4:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 11/07/22 at 4:45 p.m., the Regional Manager was notified of the IJ situation. On 11/08/22 at 11:30 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated 11/07/22, read in part: Plan of Removal Anticoagulant Therapy: Immediate Actions: 1. Review of facility records identified 3 residents on Coumadin therapy with identified resident #63 out to hospital. 2. Inservice started for Nursing staff regarding the following: a. Coumadin (Anticoagulant therapy Clinical Protocol P&P) b. Lab requirements for anticoagulant therapy to include routine draws of PT/INR c. Ensuring Physician orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2026-06-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident did not physically abuse another resident for 1 (#11) of 5 sampled residents reviewed for abuse. The DON identified 69 residents resided in the facility. Findings: An undated Abuse Policy and Procedure, read in part, We will endeavor to protect our occupants from maltreatment, which means any exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of property. A nurse progress note, dated 12/22/25, showed Resident #11 tried to take a plate of food from another unnamed resident. The unnamed resident refused to release the tray. The note showed Resident #11 grabbed the unnamed resident's arm and clawed them. The altercation resulted in a skin tear to unnamed resident's right forearm with moderate bleeding. The note showed the two residents then tried to hit each other but were separated by CNAs and nurse. The note showed Resident #11 had been up all night wandering around taking things that were not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure infection control was maintained during finger stick blood sugar checks and insulin injections for 7 (#12, 13, 14, 15, 16, 17, and #18) of 7 sampled residents observed for infection control. The regional consultant identified 19 residents required finger stick blood sugar checks. Findings: On 06/10/26 at 12:02 p.m., LPN #1 was observed obtaining Resident #12's FSBS. LPN #1 lanced Resident #12's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure. On 06/10/26 at 12:04 p.m., LPN #1 was observed obtaining Resident #13's FSBS. LPN #1 lanced Resident #13's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure. On 06/10/26 at 12:08 p.m., LPN #1 was observed administering an insulin injection to Resident #13. LPN #1 was not observed to have worn gloves during the insulin injection. On 06/10/26 at 12:10 p.m., LPN #1 was observed obtaining Resident #14's FSBS. LPN #1 lanced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report an allegation of physical abuse for 1 (#11) of 1 sampled resident reviewed for abuse. The DON identified 69 residents resided in the facility. An undated Abuse Policy and Procedure, read in part, All allegations of resident maltreatment, including neglect, physical abuse .shall be promptly reported to Administrator and investigated by Facility management. Administrator will immediately report the allegation to the Oklahoma State Department of Health and the Local Police. An Acknowledgement of Resident Rights Training which includes Abuse, Neglect, Misappropriation of Property and Burnout, signed by RN #1 on 08/23/25, read in part, I understand the definition of abuse .I also understand when and to whom I am to report any violation of resident rights and what my participation is expected to be during any investigation of an allegation of such. Two actions to be taken immediately are stopping the abuse and reporting it to my…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0564 — isolatedInform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
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 residents were allowed to have visitors of their choice for 1 (#1) of 3 sampled who were reviewed for visitation. The administrator identified 71 residents resided in the facility. Resident #1's face sheet, dated 01/22/25, showed the resident had diagnoses which included depression and hypertension. A quarterly MDS, dated [DATE], showed the residents cognition was moderately impaired with a BIMS score of 11. An undated policy titled, Visitation, read in part, 2. The facility provides 24-hour access to all individuals visiting with the consent of the resident. On 05/21/25 at 8:20 a.m., Resident #1 stated their grandson would not allow the resident's daughter to visit them in their room. Resident #1 stated they had discussed this with the social services director but nothing was done about it. Resident #1 stated they would like to have their daughter visit in their room for privacy, but their grandson had told the staff they wanted a witness to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-03 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive assessment was completed within fourteen days after admission for 2 (#58 and #70) of 2 sampled residents reviewed for assessments. The regional director of operations identified four residents who had been admitted to the facility in the last 30 days. Findings: 1. Res #58 was admitted on [DATE] with diagnoses which included type II diabetes mellitus and bipolar disorder. The clinical record contained no comprehensive admission assessment. 2. Res #70 was admitted on [DATE] with diagnoses which included Parkinson's disease and protein-calorie malnutrition. The clinical record contained no comprehensive admission assessment. On 04/03/25 at 1:20 p.m. the MDS coordinator stated they were behind in completing comprehensive admission assessments. They stated a comprehensive admission assessment for Res #58 and Res #70 had not been completed since admission. The MDS coordinator stated the comprehensive admission assessment for Res #58…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-03 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
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 facilty failed to ensure a quarterly assessment was completed for 5 (#23, 27, 40, 41, and #46) of 13 residents sampled for MDS assessments. The regional director of operations identified 65 residents resided in the facility. Findings: 1. Res #23 had an annual assessment dated [DATE]. A quarterly assessment with a reference date of 01/19/25 was not completed. 2. Res #27 had an annual assessment dated [DATE]. A quarterly assessment with an assessment reference date of 01/06/25 was not completed. 3. Res #40 had a discharge-return anticipated assessment dated [DATE] and an entry assessment dated [DATE]. A quarterly assessment with an assessment reference date of 12/11/24 was not completed. 4. Res #41 had a significant change assessment dated [DATE]. A quarterly assessment with a reference date of 02/26/25 was not completed. 5. Res #46 had a quarterly assessment dated [DATE]. A quarterly assessment with a reference date of 01/08/25 was not completed. On 04/03/25 at 1:05 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-03 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed: a. upon admission to the facility for 2 (#58 and #70) of 2 residents sampled for new admissions; b. for bed rail use for 2 (#13 and #41) of 2 residents sampled for accidents; and c. for hospice services for 1 (#46) of 1 resident sampled for hospice services. The regional director of operations identified 65 residents resided in the facility. They identified four residents who were admitted in the last thirty days. Findings: 1. Res #58 was admitted on [DATE] with diagnoses which included type II diabetes mellitus and bipolar disorder. The clinical record contained no comprehensive care plan. 2. Res #70 was admitted on [DATE] with diagnoses which included Parkinson's disease and protein-calorie malnutrition. The clinical record contained no comprehensive care plan. On 04/03/25 at 1:29 p.m. the MDS coordinator stated they were behind in developing care plans. They stated a comprehensive 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.
- Potential for harm · E2025-04-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident who entered the facility with an indwelling urinary catheter had a physician order and was assessed for the use for 1 (#7) of 1 sampled resident reviewed for the use of an indwelling urinary catheter. The DON identified 11 residents with indwelling urinary catheters. Findings: On 03/31/25 at 1:10 p.m., the resident was lying in a low bed and had a indwelling urinary catheter hanging from their bedside. Resident #7 had diagnoses which included urinary tract infection and diabetes mellitus. A 5 day assessment, dated 02/13/25, showed the resident was cognitively intact and had a BIMS score 12. The assessment showed the resident was always continent of bladder. A treatment administration record/medication administration record for April 2025 did not show catheter care for the resident. There was no current physician order for an indwelling catheter when Resident #7 returned from the hospital on [DATE]. On 03/31/25 at 1:14…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-03 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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 provide all monthly medication regimen reviews from January 2024 through February 2025 for 5 (#20, 23, 37, 41, and #49) of 5 sampled residents reviewed for unnecessary medications. The DON identified 65 residents resided in the facility. Findings: A policy titled Monthly Medication Regimen Reviews, revised May 2024, read in part, The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medications. Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated .Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. 1. Res #49 was admitted with diagnoses which included dementia and bipolar disorder. A quarterly assessment, dated 11/30/24, showed Res #49 was cognitively intact with a BIMS score of 14 and had no depression or behaviors. The assessment showed Res #49 received antipsychotic,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to label and date food items in the walk in refrigerator. The dietary manager identified 65 residents who ate meals prepared by the kitchen. Findings: On 03/31/25 at 10:44 a.m., a kitchen observation was made. The walk in refrigerator had a container with scrambled eggs and two sausage links that were not labeled or dated. There was a container of meat in six plastic bags, with one open to air, that were not labeled or dated. There was a large container not labeled or dated the DM identified as vanilla pudding. A policy titled Food Receiving and Storage, revised October 2024, read in part All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). On 03/31/25 at 10:50 a.m., the DM stated items in the refrigerator should be labeled and dated.
- Potential for harm · Ecited before2025-04-03 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to maintain an infection control program for EBPs for 3 (#7, 12, and #70) of 3 sampled residents reviewed for infection control practices. The DON identified 11 residents with indwelling urinary catheters, six residents with wounds, and one resident with a PEG tube. Findings: A policy titled Enhanced Barrier Precautions, dated August 2022, read in part, Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator .and h. wound care (any skin opening requiring a dressing). 1. On 04/01/25 at 2:20 p.m., LPN #1 was observed gathering supplies to complete wound care for 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.
Show the remaining 22 citations
- Potential for harm · D2025-04-03 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a significant change resident assessment was completed when a resident was placed on hospice services for 1 (#46) of 2 sampled residents reviewed for hospice services. The MDS coordinator identified 16 hospice residents resided in the facility. Findings: Res #46 admitted to the facility with diagnoses of unspecified dementia, anxiety, and depressive disorders. A physician's order, dated 02/06/25, showed admit to hospice. There was no documentation a significant change resident assessment was completed when Resident #46 began hospice services. On 04/03/25 at 11:49 a.m., the MDS coordinator reported a significant change should have been completed.
- Potential for harm · Fcited before2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure the ice machine in the lobby remained locked. The DON reported 61 residents resided in the facility. Findings: On 12/11/23 09:20 a.m., the ice Machine is located in the lobby and observed to be unlocked. On 12/13/23 9:21 a.m., the ice machine which is in the dining room was observed to be unlocked. On 9:23 a.m., the regional director stated the ice machine should be locked and they get a tag for that every year.
- Potential for harm · Ecited before2023-12-14 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure assessments were encoded and transmitted to CMS in the required time frame for three (#7, 47 and, #50) of 18 residents whose assessments were reviewed. The Long-Term Care Facility Application for Medicare and Medicaid form documented 61 residents resided in the facility. Findings: 1. Res #7's quarterly assessment, dated 11/09/23, documented transmitted. The final validation report documented the assessment was transmitted 12/11/23. 2. Res #47's quarterly assessment, dated 11/06/23, documented transmitted. The final validation report documented the assessment was transmitted 12/11/23. 3. Res #50's annual assessment, dated 11/09/23, documented transmitted. The final validation report documented the assessment was transmitted 12/11/23. On 12/13/23 at 9:20 a.m., the MDS coordinator stated the assessments were transmitted late for the named residents. The MDS coordinator stated they input the information into the system but then it sometimes takes a while to get them transmitted. The MDS coordinator stated she had been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
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 obtain a physician order for oxygen needs for one (#50) and failed to provide oxygen as ordered by the physician order for one (#3) of three sampled residents for respiratory therapy. Findings: Res #50 was admitted to the facility with diagnoses of COPD, bipolar disorder, and anxiety disorder. On 12/12/23 at 10:17 a.m., the resident was observed resting in bed with eyes closed. The resident was observed wearing oxygen on at 2 liters per minute via nasal canula. On 12/13/23 at 8:50 a.m., the resident's record was reviewed and did not document a physician's order for oxygen. LPN #1 was asked to review the resident's physician orders and she reported the resident did not have and order for oxygen therapy. On 12/13/23 at 10:13 a.m., the corporate nurse reported the resident should have had an order for oxygen. Res #3 was admitted to the facility with diagnoses of hypoxia, congestive heart failure, bipolar disorder, and Alzheimer's disease. A physician's order, dated 07/15/22, documented oxygen @ 4LPM via nasal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 medications were administered according to physician's order for two (#3 and #12) of eight sampled residents reviewed for medication administration. The BOM identified 61 residents resided in the facility. Findings: An Administering Medications policy, dated December 2022, read in part, .Medication must be administered in accordance with the orders, including any required time frame . 1. Resident #12 had diagnoses which included colostomy status. A Physician's Orders, dated 03/23/23, documented Colace 100 mg was to be administered at bedtime. 2. Resident #3 had diagnoses which included gastro-esophageal reflux disease. A Physician's Orders, dated 07/22/22, documented Protonix every day at 11:00 a.m. On 12/13/23 at 7:40 a.m., CMA #3 was observed to administer Colace to Resident #12. On 12/13/23 at 8:00 a.m., CMA #2 was observed to administer Protonix to Resident #3. On 12/13/23 at 8:15 a.m., CMA #3 was asked what the process was for ensuring medications were administered as ordered. They stated they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-14 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure PRN psychotropic medications were limited for four (#34, 45, 50, and #39) of five sampled residents reviewed for unnecessary medications. The Regional Director identified 36 residents received psychotropic medications. Findings: An Antipsychotic Medication Use policy, dated December 2022, read in part, .The need to continue PRN orders for psychotic medications beyond 14 days requires that the practitioner document the rationale for the extended order . 1. Resident #45 had diagnoses which included anxiety. A Physician's Orders, dated 10/16/23, documented Ativan was to be administered every six hours as needed for anxiety. There was no documentation limiting the use of the medication. Resident #45's MAR, from November and December 2023, documented the resident received five doses beyond the 14 days limitation as documented in the facility's policy. There was no documentation the physician provided a rationale for extending the order. On 12/13/23 at 10:52 a.m., the ADON was asked if Resident #45 received PRN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 28 opportunities were observed with two errors. The total medication error rate was 7.14%. The BOM identified 61 residents resided in the facility. Findings: 1. Resident #12 had diagnoses which included colostomy status. A Physician's Orders, dated 03/23/23, documented Colace 100 mg was to be administered at bedtime. 2. Resident #3 had diagnoses which included gastro-esophageal reflux disease. A Physician's Orders, dated 07/22/22, documented Protonix every day at 11:00 a.m. On 12/13/23 at 7:40 a.m., CMA #3 was observed to administer Colace to Resident #12. On 12/13/23 at 8:00 a.m., CMA #2 was observed to administer Protonix to Resident #3. On 12/13/23 at 8:15 a.m., CMA #3 was asked what the process was for ensuring medications were administered as ordered. They stated they followed the MAR. CMA #3 was asked to when was the Colace administered. They were observed to look at the MAR and stated, My bad. I made a mistake. On 12/13/23 at 8:47 a.m., CMA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interview, the facility failed to ensure refrigerated medications were stored in a manner to maintain the integrity of the medications and failed to dispose of expired medications and supplies by the expiration dates. The Long-Term Care Facility Application for Medicare and Medicaid form documented 61 residents resided in the facility. Findings: A facility policy, dated April 2023, read in part, Storage of Medications .Discontinued, outdate, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately food and are labeled accordingly . On 12/13/23 at 10:23 a.m., the medication room was observed. A total of 47 prefilled heparin syringes were expired and 11 IV tubing's in packages were expired in the medication room. On 12/13/23 at 10:25 a.m., CMA #3 stated they look for expired medication once a month. CMA #3 stated the TB testing solution was kept in 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.
- Potential for harm · D2023-12-14 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accurate for one (#3) of 24 sampled residents whose assessments were reviewed for accuracy. The DON reported 61 residents resided in the facility. Findings: Res #3 was admitted to the facility with diagnoses of hypoxia, congestive heart failure, bipolar disorder, and Alzheimer's disease. A physician order, dated 07/15/22, documented oxygen at 4 liters per minute via nasal canula. A quarterly assessment, dated 08/24/23, contained no documentation the resident required oxygen therapy. On 12/13/23 at 1:12 p.m., the MDS coordinator reported the assessment should have documented oxygen therapy.
- Potential for harm · D2023-12-14 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#39) of one sampled residents reviewed for PASRR. The DON reported 61 residents resided in the facility. Findings: The resident's record documented the resident was re-admitted to the facility on [DATE] with diagnoses of paranoid personality disorder and delusional disorders. On 12/13/23 at 1:12 p.m., the regional director and the MDS coordinator reported the OHCA should have been notified of the new mental health diagnoses.
- Potential for harm · Dcited before2023-12-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 physician responded to the pharmacist gradual dose reductions for one (#33) of five sampled residents reviewed for unnecessary medications. The BOM identified 61 residents resided in the facility. Findings: 1. Resident #33 had diagnoses which included delusional disorder. A Physician's Orders, dated 05/19/23, documented Resident #33 received Remeron 45 mg once a day, and Seroquel 50 mg twice a day. A medication regimen review, dated 09/29/23, documented a request to the physician to attempt a decrease in the dose of the Remeron. A medication regimen review, dated 10/31/23, documented a request to the physician to consider a dose reduction of the Seroquel. There was no response from the physician for either medication regimen review. On 12/13/23 at 10:01 a.m., the ADON was asked what the process was for obtaining the response from the physician regarding medication regimen reviews. They stated they would send them to the physician for review. They stated they usually got the response back in a week. The ADON was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure staff did not touch medications, to be administered to residents, with un-gloved hands. The BOM identified 61 residents resided in the facility. Findings: On 12/13/23 at 7:55 a.m., CMA #2 was observed to pick up a pill from a medication cup with there un-gloved hand and placed in a different medication cup. CMA #2 was observed to administer medications to the resident. On 12/13/23 at 8:40 a.m., CMA #2 was observed to hold medication in a medication cup with their un-gloved hand and let other medication fall into a pill crusher pouch. CMA #2 was observed to administer medication to the resident. On 12/13/23 at 8:47 a.m., CMA #2 was asked what the policy was for touching medication with their hands. They stated they were suppose to wear gloves. CMA #2 was asked if they wore gloves. They stated, Not each time. On 12/13/23 at 12:35 p.m., the ADON was asked what the policy was for touching medication. They stated the staff should wear gloves.
- Potential for harm · E2023-10-13 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to document and retain daily staffing information for the past 18 months. The Resident Census and Conditions of Resident form, dated 10/12/23 documented a census of 55 residents. Findings: On 10/12/23 at 6:00 a.m., a white board behind the nurse's station was observed to include documentation of the census number, name and titles of staff on duty. Staffing hours were not documented. On 10/12/23 at 1:00 p.m., the regional consultant was unable to provide staff assignments for the last six months and reported they were unaware of the requirements to post staffing hours and retain the documentation for 18 months.
- Potential for harm · E2022-11-08 · tag F0727 — failed to provide required RN coverage — patternHave 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 the Director of Nursing did not work as the charge nurse when the census was greater than 60. The Resident Census And Conditions of Residents, dated 11/01/22, documented a census of 65 residents. Findings: On 11/07/22 at 8:45 a.m., the DON reported they had worked as the charge nurse on 10/24/22, 10/25/22, 10/31/22, 11/01/22, and 11/04/22. On 11/07/22 at 9:10 a.m., the office manager reported the census on 10/24/22 and 10/25/22 was 63, on 10/31/22 the census was 62, on 11/01/22 the census was 68, and on 11/04/22 the census was 66. On 11/07/22 at 9:15 a.m., the regional manager reported the DON should not have worked as the charge nurse when the census was above 60.
- Potential for harm · Ecited before2022-11-08 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 record review, observation, and interview, the facility failed to ensure narcotics were stored in a permanently affixed locked compartment and medication carts were locked when unattended. The Resident Census And Conditions of Residents, dated 11/01/22, documented a census of 65 residents. Findings: 1. A Controlled Substances policy, updated 07/21, read in parts, Controlled substances must be stored in the medication room in a locked container .Locked containers for storage must be secured and non removable. On 11/03/22 at 9:36 a.m., in the medication storage room, two liquid Ativan's (a controlled substance for anti-anxiety) were observed on a shelf in the refrigerator. The Ativan was not in a permanently affixed locked compartment. On 11/03/22 at 9:37 a.m., LPN #1 stated the Ativan should have been stored in a permanently affixed locked compartment. On 11/03/22 at 9:45 a.m., the DON reported the Ativan should have been in a permanently affixed locked compartment. On 11/03/22 at 10:00 a.m., the regional manager reported the Ativan should have been in permanently affixed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-08 · tag F0636 — isolatedAssess 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were completed within 14 days of admission for two (#14 and #64) of two residents reviewed for comprehensive assessments. The Resident Census and Conditions of Residents, dated 11/01/22, documented a census of 65 residents. Findings: The Comprehensive Assessments and the Care Delivery Process policy, revised 12/16, documented in part .complete the Minimum Data Set within 14 days after admission . Res #14 was admitted on [DATE]. A comprehensive assessment, dated 07/05/22, was completed on 09/02/22. Res #64 was admitted on [DATE]. A comprehensive assessment, dated 04/18/22, was completed on 05/06/22. On 11/03/22 at 9:40 a.m., the MDS coordinator reported the comprehensive assessments for Res #14 and Res #64 were not completed within 14 days of admission. On 11/03/22 at 9:45 a.m., the regional manager reported the comprehensive assessments should have been completed within 14 days of admission.
- Potential for harm · Dcited before2022-11-08 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure quarterly assessments were completed every three months for four (#6, 14, 61 and #64) of four residents reviewed for quarterly assessments. The Resident Census and Conditions of Residents, dated 11/01/22, documented a census of 65 residents. Findings: Res #6 was admitted on [DATE]. A quarterly assessment, dated 08/29/22, was completed on 09/23/22. Res #14 was admitted on [DATE]. A quarterly assessment, dated 10/05/22, was not completed. Res #61 was admitted on [DATE]. A quarterly assessment, dated 10/02/22, was not completed. Res #64 was admitted on [DATE]. A quarterly assessment, dated 07/19/22, was completed on 09/02/22. On 11/03/22 at 9:40 a.m., the MDS coordinator reported the assessments were not completed or were completed late. On 11/03/22 at 9:45 a.m., the regional manager reported the expectations were that assessments were to be completed within the RAI time frame.
- Potential for harm · Dcited before2022-11-08 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to transmit resident assessments to CMS within 14 days of the completion date for three (#6, 14, and #126) of three residents reviewed for resident assessments. The Resident Census And Conditions of Residents, dated 11/01/22, documented 65 residents resided in the facility. Findings: The CMS Submission Report, dated 09/02/22, 09/23/22, and 10/07/22 documented: Res #6 was admitted on [DATE]. A resident assessment, dated 08/29/22, was submitted to CMS on 09/23/22. Res #14 was admitted on [DATE]. A resident assessment, dated 07/05/22, was submitted to CMS on 09/02/22. Res #126 was admitted on [DATE]. Resident assessments dated 09/07/22, 09/08/22, 09/14/22, and 09/17/22 were submitted to CMS on 10/07/22. On 11/03/22, at 9:40 a.m., the MDS coordinator stated the resident assessments were submitted late. On 11/04/22, at 9:45 a.m., the regional manager stated the resident assessments should have been submitted within 14 days of the completion date.
- Potential for harm · D2022-11-08 · tag F0642 — isolatedEnsure a qualified health professional conducts resident assessments.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a registered nurse coordinated and signed the resident assessments prior to submission to CMS for one (#126) of one resident reviewed for resident assessments. The Resident Census and Conditions of Residents, dated 11/01/22, documented a census of 65 residents. Findings: The following re-entry resident assessments for Res #126 were transmitted to CMS without RN coordination and signature on 09/07/22, 09/14/22, and 10/03/22. On 11/03/22, at 9:40 a.m., the MDS coordinator reported the assessments were not signed by the RN coordinator. On 11/03/22, at 9:45 a.m., the regional manager stated the assessments were to be signed by the RN coordinator within the RAI time frame.
- Potential for harm · D2022-11-08 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to develop/implement baseline care plans for three (Res #19, 20, and Res #126) of 10 residents sampled for baseline care plans. The Resident Census and Conditions of Residents, dated 11/01/22, documented a census of 65 residents. Findings: The Care Plans, Comprehensive Person-Centered policy, revised 12/16, documented in parts, A comprehensive person-centered care plan .is developed and implemented for each resident .within seven (7) days of the completion of the required comprehensive assessment . 1. Res #19 was admitted with diagnoses which included heart disease and dementia. A quarterly assessment, dated 07/14/22, documented Res #19 was cognitively intact, used a walker and wheelchair to ambulate, and was occasionally incontinent of bladder. An undated, Resident Baseline Care Plan, with no signature, documented Res #19 was legally blind, required assistance with toileting, and utilized a rolling walker when ambulating. The care plan did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to attempt a gradual dose reduction (GDR) for two (#40 and #47) of four residents reviewed for unnecessary medication. The Resident Census and Conditions of Residents, dated 11/01/22, documented 15 residents were taking antipsychotics. Findings: Res #40 was admitted with diagnoses which included dementia with behavorial disturbance. A physician's order, dated 08/10/22, read in part, Risperdal (an antipsychotic medication) 1 mg I PO BID On 11/07/22 at 1:00 p.m., the Regional Manager reported no GDR had been attempted. On 11/07/22 at 2:15 p.m., the DON reported no GDR had been attempted. Res #47 was admitted with diagnoses which included dementia. A physician's order, dated 08/23/22, read in part, Seroquel (an antipsychotic medication) 50mg 1 PO HS. On 11/07/22 at 1:00 p.m., the Regional Manager reported no GDR had been attempted. On 11/07/22 at 2:15 p.m., the DON reported no GDR had been attempted.
- Potential for harm · Dcited before2022-11-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure facemasks were properly worn by staff. The Resident Census And Conditions of Residents, dated 11/01/22, documented a census of 65 residents. Findings: A Staff Request for Religious Exemption to the COVID-19 Vaccination Requirement, dated 02/25/22, was signed by CMA #1 requesting exemption from the COVID-19 vaccination. The COVID-19 Plan for Non-Masking policy, dated 10/22, read in part, All unvaccinated HCP [health care providers] must wear a minimum of a well-fitting facemask regardless of Community Transmission Level or area worked. On 11/04/22 at 8:00 a.m., CMA #1 was observed at the front nurse's station with a facemask below their nose while residents were present. On 11/04/22 at 8:06 a.m., CMA #1 was observed on the 300 hall with the facemask below their nose. On 11/04/22 at 8:15 a.m., the IP reported facemasks were to be worn with the nose covered. The IP reported CMA #1 had been granted an exemption and was not vaccinated. On 11/04/22 at 8:21 a.m., the regional manager reported the CMA's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.2 | -1.2 vs chain |
| Health inspection | 1 of 5 | 2.5 | -1.5 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 2.9 | -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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MONTGOMERY, BRADFORD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/28/2013 |
| TOWNSEND, MITCHELL | Individual | W-2 MANAGING EMPLOYEE | — | since 03/17/2015 |
| WHITLEY, TINA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 04/01/2018 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $303K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375434. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-03, 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.