Hennessey Nursing & Rehab
705 East 3rd Street, Hennessey, OK 73742 · For profit - Limited Liability company · 50 certified beds · (405) 853-4390 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $33,924 in federal fines (most recent 2024-04-15)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 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 | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 20.5% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.1% | 3.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 3.6% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.9% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 15.1% | 3.4% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.1% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.1% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.5% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.7% | 17.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.2% | 17.5% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.87 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.97 | 2.96 | 1.80 | typical |
‡ 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.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 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 50 beds and averages 29.8 residents a day — about 60% occupied, or roughly 20 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.
Weekend coverage: total nurse staffing is 4.50 hrs/resident/day on weekends vs 5.36 on weekdays — 16% thinner on weekends. RN hours go from 0.37 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · J2024-04-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 04/11/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a resident experiencing a significant change in condition and ensure a resident received prescribed antibiotic therapy to treat pneumonia. 03/08/24 Resident #1 had acute change of condition, very weak, unable to stand/sit, 3-4 person assist to transfer, irregular HR, O2 sats 80%, incontinent B&B, and decline in mental status. MD notified. Not sent to ER. 03/19/24 Resident #1's condition deteriorates and they requested to be sent to ER. Returned from ER same day with DX: pneumonia and orders for Augmentin 875mg-125mg tab- 1 tab oral q12hrs x7days. Their physician was not notified of new order, the medication order was not submitted to the pharmacy, and the medication was not placed on the MAR. There was no documentation that Augmentin was ever ordered, received from the pharmacy, or given to the resident between 03/19/24 and 04/08/24. 03/26/24 Nursing staff documented…
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 · G2024-04-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to accurately assess residents' risk for and initiate dietary measures to aide in the prevention of avoidable pressure ulcers for one (#1) of two sampled residents reviewed for pressure ulcers. The Administrator identified 31 residents resided in the facility. Findings: Resident #1 had diagnoses that included s/p amputation of left toes and PICC line in upper right arm. Resident #1's Care Plan documents, on 03/15/24, resident was at risk of nutritional decline and had lost 12 lbs. in a month. The RD completed a 'Nutrition Risk Assessment' for Resident #1, dated 03/18/24, with a risk score of NO/LOW RISK, and no interventions for prevention of pressure ulcers were put into place. Discrepancies in the RD assessment included: 1. RD documented no weight loss/gain- weight record documented a weight loss of <5% since admission. Resident #1's documented weights include 176 lbs. on 02/28/24, 172 lbs. on 03/11/24, 168 lbs. on 03/22/24, 164 lbs. on 03/27/24, and 160.5 lbs. on 04/05/24. 2. RD documented oral/nutrition intake meets…
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 · F2026-03-26 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 post the most recent state survey results in a place readily accessible to residents, family members, and legal representatives of the residents. The administrator identified 27 residents resided in the facility.Findings: On 03/25/26 at 11:27 a.m., the surveyor walked the halls and the lobby of the facility, there was no posting showing were to find the survey results binder. A Survey Results, Examination of policy, revised 04/2007, read in part, A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plan of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. On 03/25/26 at 11:01 a.m., 10 resident council members present for the meeting stated they did not know where to find the state survey results. On 03/25/26 at 11:30 a.m., the Administrator stated there was a little card on the table where the results…
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 · F2026-03-26 · tag F0727 — failed to provide required RN coverage — widespreadHave 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 — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.The administrator identified 27 residents resided in the facility. Findings: A Staffing policy, updated 10/2023, read in part, RN must be on duty 8 hours a day 7 days a week. A PBJ Staffing Data Report, dated 10/01/25 through 12/31/25, showed no RN hours on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25. An Employee Timecard Report dated 10/01/25 through 12/31/25, did not show the facility had RN hours for 8 consecutive hours on the following dates, 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25. On 03/26/26 at 12:45 p.m., the MDS coordinator stated yes those are the only three RN's for the facility. They stated the facility did not have RN coverage on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, or 12/18/25.On 03/26/26 at 1:04 p.m., the Administrator stated they were not aware the facility did not have coverage on 10/13/25, 10/14/25, 10/27/25, 11/10/25,…
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 · F2026-03-26 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure the food service supervisor completed certification as a certified dietary manager within three years of beginning employment per State requirement.The administrator identified 27 residents who received meals from the kitchen. Findings:The Food and Nutrition Services Staff policy, revised 10/20, read in part, Nutrition service manager if not already certified will be enrolled in an accredited/approved program within regulatory timeframe.An undated Employee Information Report, showed the dietary supervisor was hired on 02/04/20.There was no documentation the dietary supervisor had completed a certified program.On 03/23/26 at 1:47 p.m., the dietary supervisor stated they have not completed a certification course. On 03/26/26 at 9:35 a.m., the administrator stated they were aware the dietary supervisor was not certified. They stated the dietary supervisor was hired for their role on 02/04/20.
- Potential for harm · E2026-03-26 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to notify a physician of a resident's change in condition for 1 (#24) of 1 sampled resident reviewed for self-administration of medication.The DON identified nine residents who received breathing treatments in the facility.Findings:The Acute Condition Changes-Clinical Protocol policy, revised 03/18, read in part, The nursing staff will contact the physician based on urgency of the situation.Resident #24's quarterly resident assessment, dated 01/27/26, showed the resident had diagnoses which included chronic obstructive pulmonary disease and cough. It showed the resident's cognition was intact with a BIMS of 15.A physician's order, dated 02/03/26, showed ipratropium-albuterol (a bronchodilator breathing treatment) inhalation solution 0.5-2.5, 3 mg/3ml. Inhale one vial three times a day for wheezing.The March 2026 Orders Administration notes showed Resident #24 refused ipratropium-albuterol treatment on the;a. 4th at 8:46 p.m. due to, It makes me shake too bad,b. 5th at 9:04 p.m.,c. 9th at 8:48 p.m. due to, It makes me shake…
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 · D2026-03-26 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 resident had a physician order and an assessment to self-administer medications for 1 (#24) of 1 sampled resident reviewed for self-administration of medication.The DON identified nine residents who received breathing treatments in the facility.Findings:On 03/24/26 at 8:42 a.m., there were two vials of ipratropium bromide/albuterol sulfate 0.5-3 mg in 3 ml sitting on the Resident #24's bedside table.Resident #24's quarterly resident assessment, dated 01/27/26, showed the resident had diagnoses which included chronic obstructive pulmonary disease and cough. It showed the resident's cognition was intact with a BIMS of 15.A physician's order, dated 02/03/26, showed ipratropium-albuterol (a bronchodilator breathing treatment) inhalation solution 0.5-2.5, 3 mg/3ml. Inhale one vial three times a day for wheezing.There was no documentation the Resident #24 had an assessment and a physician's order for self-medication administration.On 03/24/26 at 8:43 a.m., Resident #24 stated the nurse gave them 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 · Dcited before2026-03-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the care plan was revised to show a new skin alteration for 1 (#28) of 3 residents reviewed for care plans.The administrator reported 27 residents resided in the facility.Findings:A Care Plans, Comprehensive Person-Centered policy, revised 12/2016, read in part, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions of change. Resident #28's care plan, initiated on 03/06/25, showed resident had diagnoses which included cerebral palsy and major depressive disorder. An Incident Note, dated 12/04/25 at 12:01 p.m., read in part, During a transfer utilizing the mechanical lift [name withheld], the res stated, The chair pinched me.A review of Resident #28's care plan did not show documentation of a laceration. Upon transfer back to bed 3 superficial lacerations were noted to the gluteal area regions. An Incident Note, dated 12/04/25 at 4:00 p.m., read in part, New order received; Cleanse lacerations with wound cleaner and pat dry daily and as needed…
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 before2026-03-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident's breathing treatment was accurately documented for 1 (#24) of 1 sampled resident reviewed for self-administration of medication.The DON identified nine residents who received breathing treatments in the facility.Findings:On 03/24/26 at 8:42 a.m., there were two vials of ipratropium bromide/ albuterol sulfate 0.5-3 mg in 3 ml sitting on the Resident #24's bedside table.The Charting and Documentation policy, revised 07/17, read in part, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.Resident #24's quarterly resident assessment, dated 01/27/26, showed the resident had diagnoses which included chronic obstructive pulmonary disease and cough. It showed the resident's cognition was intact with a BIMS of 15.A physician's order, dated 02/03/26, showed ipratropium-albuterol (a bronchodilator breathing treatment) inhalation solution 0.5-2.5, 3 mg/3ml. Inhale one vial three times a day for wheezing.The March 2026 treatment administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-07 · tag F0700 — patternTry 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 complete bed rail safety assessments, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to installation of bed rails for three (#13, #15, and #82) of three sampled residents with bed rails in use. The DON identified 33 residents resided in the facility. Findings: A Bed Safety and Bed Rails' policy, revised August 2022, read in parts, .3. The use of bed rails or side rails .is prohibited unless the criteria for use of bed rails have been met, including .interdisciplinary evaluation, resident assessment, and informed consent . 1. On 08/04/24 at 12:25 p.m., Resident #13 was observed in bed with two upper bed rails raised. 2. On 08/04/24 at 2:05 p.m., Resident #15 was observed in bed with two upper bed rails raised. 3. On 08/05/24 at 12:58 p.m., Resident #82 was observed in bed with two upper bed rails raised. There was no documentation in the clinical records of Resident #13, #15, nor #82 that bed rail safety assessments had been completed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-07 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure influenza and pneumococcal vaccinations were offered for four (#15, 18, 22, and #82) of five residents reviewed for immunizations. The DON identified 33 residents resided in the facility. Findings: Immunization records for Residents #15, #18, #22, and #82 were reviewed. There was no documentation in their record the residents, nor their representatives had been offered or received an influenza or pneumonia immunization. On 08/07/24 at 9:41 a.m., the DON was asked if residents were offered influenza and pneumonia vaccines. They stated immunizations should be offered during admission process and annually. The DON acknowledged neither Resident #15, #18, #22, nor #82 or their representative had documentation in their clinical record showing they were offered nor received the influenza or pneumococcal vaccines.
- Potential for harm · D2024-08-07 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — 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 not involuntarily discharged for one (#30) of three sampled discharged residents. The DON identified 33 residents resided in the facility. Findings: Resident #30 was admitted on [DATE] with diagnoses that included anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. A physician's order, dated 06/25/24 at 7:48 p.m., read in parts, .Transfer to VA hosp ER D/T behaviors . There was no documentation in the clinical record that the facility followed-up on Resident #30's status after he was transferred to the VA hospital ER and no documentation stating the resident had been discharged . On 08/06/24 at 9:33 a.m., the DON stated Resident #30 did not return to the facility because they were a danger to self and others due to their behaviors. They stated they could not meet Resident #30's needs at the facility. On 08/06/24 at 11:50 a.m., Nurse Consult. #1, who completed the transfer MDS for Resident #30, 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.
Show the remaining 20 citations
- Potential for harm · D2024-08-07 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — 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 provide notice of a facility initiated discharged for one (#30) of three sampled discharged residents. The DON identified 33 residents resided in the facility. Findings: Resident #30 was admitted on [DATE] with diagnoses that included anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. A nurse's note, dated 06/25/24 at 8:10 p.m., documented Resident #30 was transferred to the VA hosp ER D/T behaviors. A Discharge summary, dated [DATE], documented Resident #30 had been discharged from the facility on 06/25/24. There was no documentation in the clinical record that the facility notified, or attempted to notify, Resident #30 or their family of their discharge from the facility. On 08/06/24 at 9:33 a.m., the DON acknowledged neither Resident #30 nor their family had been notified of their discharge from the facility.
- Potential for harm · D2024-08-07 · 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 a discharge MDS assessment was completed within the required timeframe for one (#11) of three sampled residents whose discharge assessments were reviewed. The DON identified 33 residents resided in the facility. Findings: Resident #11 was admitted to the facility on [DATE] and discharged at the end of their skilled days on 04/12/24. The EHR did not document a discharge MDS assessment had been completed. On 08/06/24 at 11:40 a.m., Nurse Consult. #1 acknowledged the discharge MDS assessment for Resident #11 had not been completed.
- Potential for harm · D2024-08-07 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a baseline care plan was completed in a timely manner for one (#131) of 12 sampled residents reviewed for baseline care plans. The DON identified 33 residents resided in the facility. Findings: Resident #131 was admitted on [DATE]. Resident #131's baseline care plan documented a completion date of 07/27/24. On 08/06/24 at 8:16 a.m., Nurse Consult. #1 stated Resident #131's baseline care plan was not completed in a timely manner. They stated a baseline care plan was to be completed within 48 hours of admission.
- Potential for harm · D2024-08-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to implement a comprehensive care plan for one (#132) of one sampled resident reviewed for the use of a urinary catheter. The DON identified 33 residents resided in the facility. Three residents had urinary catheters in the facility. Findings: Resident #132 was admitted on [DATE] with diagnoses which included neuromuscular dysfunction of bladder and hydronephrosis. A physician order, dated 07/05/24, documented to change foley catheter every 30 days on the 1st of the month on night shift. Resident #132's admission resident assessment, dated 07/11/24, documented the Resident had an indwelling catheter. On 08/04/24 at 10:31 a.m., Resident #132 was observed to have an indwelling urinary catheter. Review of Resident #132's baseline care plan did not document the use of an indwelling urinary catheter. There was no record of the completion of a comprehensive care plan for Resident #132. On 08/07/24 at 9:18 a.m., Nurse Consult. #1 stated 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.
- Potential for harm · D2024-08-07 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a discharge summary and discharge instructions were completed upon discharge for one (#11) of three sampled residents whose discharge paperwork was reviewed. The DON identified 33 residents resided in the facility. Findings: Resident #11 was admitted to the facility on [DATE] and discharged at the end of their skilled days on 04/12/24. A 'Discharge Summary' form for Resident #11, dated 02/28/24, was located in their clinical record, but it had not been completed. A Discharge Instructions form for Resident #11, was located in their clinical record undated and not completed. On 08/06/24 at 9:27 a.m., the DON acknowledged the discharge summary and discharge instructions for Resident #11 had not been completed.
- Potential for harm · D2024-08-07 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 have a process in place to identify a resident's code status for one (#131) of three sampled residents reviewed for advanced directives. Findings: Resident #131 was admitted on [DATE]. A physician's order, dated 07/23/24, documented DNR. A care plan, dated 07/27/24, documented Resident #131 preferred to be a DNR. There was no documentation of a completed Oklahoma DNR consent form in Resident #131's record. On 08/05/24 at 10:47 a.m., the DON stated Resident #131 did not have a DNR consent form in their health record. They stated residents should have a physician's order and a DNR form in their chart upon admission or remain a full code until a DNR consent form was obtained. On 08/05/24 at 11:36 a.m., LPN #1 stated residents code status were found in their health record and resident roster at the nurse's station.
- Potential for harm · D2024-08-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered by the physician and oxygen tubing was changed for one (#27) of one sampled resident reviewed for respiratory care. The DON identified two residents who received continuous oxygen therapy in the facility. Findings: The Oxygen Administration policy, revised 10/10, read in part, Review the physician's orders or facility protocol for oxygen administration. Resident #27 had diagnoses which included COPD and acute and chronic respiratory failure with hypoxia. A physician's order, dated 02/05/24, documented oxygen at 3 liters per nasal cannula to keep oxygen saturation at 90% or above. On 08/04/24 at 1:29 p.m., Resident #27 was observed receiving oxygen. The concentrator was set at 3.5 LPM. The oxygen tubing was dated 07/22. On 08/04/24 at 1:42 p.m., RN #1 stated Resident #27's oxygen order was 3 liters via nasal cannula. On 08/04/24 at 1:43 p.m., RN #1 stated oxygen tubing were to be changed weekly on Sundays. On 08/04/24 at 1:46 p.m., RN #1 observed the Resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-07 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to complete a nurse aide performance review once every 12 months for two (CNA #1 and CNA #2) of five employee files reviewed. The DON identified 33 residents resided in the facility. Findings: The Competency of Nursing Staff policy, revised 10/17, read in part, All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. CNA #2 had a hire date of 04/28/22. There was no CNA annual competency review located in the employee's file. CNA #1 had a hire date of 05/12/23. There was no CNA annual competency review located in the employee's file. On 08/06/24 at 7:59 a.m., the BOM stated there was no CNA annual competency review for CNA #1 and CNA #2.
- Potential for harm · D2024-08-07 · 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 — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to: a. implement a physician order for a gradual dose reduction for one (#26); b. have a physician response to a gradual dose reduction recommendation for one (#6) of five sampled residents reviewed for unnecessary medications. The DON identified 33 residents resided in the facility. 18 residents received psychotropic's in the facility. Findings: 1. Resident #26 had diagnoses which included insomnia and anxiety. An MRR, dated 05/28/24, documented a GDR recommendation for 150 mg trazodone (an antidepressant) reduction to 100 mg at bedtime. A physician's response, dated 06/11/24, documented agreement to the trazodone reduction. A nurse's acknowledgement, dated 06/14/24, was documented on the MRR. There was no physician's order corresponding to the nurse's acknowledgement on 06/14/24 for Resident #26. A nurse's acknowledgement, dated 06/21/24, was documented on the MRR. A physician's telephone order, dated 06/21/24, documented 100 mg trazodone one tablet by mouth at bedtime per pharmacy recommendation. The June 2024 MAR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure proper infection control practices were followed during the administration of medication for one (#13) of seven sampled residents observed during medication administration. The DON identified 33 residents resided in the facility. Findings: An 'Administration Set/Tubing Changes' policy, revised February 2023, read in parts, General Guidelines .4. Label tubing with date, time, and initials .5. Any tubing that is found not labeled must be changed and then labeled accordingly .6. Any tubing that is suspected to have been contaminated or compromised is changed immediately . Resident #13 was receiving intravenous antibiotic therapy via a PICC line in place to left upper arm. On 08/05/24 at 8:45 a.m., this surveyor observed LPN #1 during IV medication administration for Resident #13. Upon entering the resident's room, I observed there was no date on the tubing that was hanging in the previously used IV bag. LPN #1 used the hanging IV tubing to spike the new IV bag, primed the line and laid the end of the IV…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-15 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure care of a peripheral intravenous central catheter in accordance with professional standards of practice for one (#1) of one sampled resident reviewed for treatment of an intravenous catheter. The Administrator identified 31 residents resided in the facility. Findings: A 'Peripheral and Midline IV Dressing Changes' policy, revised March 2022, read in parts, 4. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM dressing; b. at least every 2 days for sterile gauze dressing .unless site is not obscured; or c. immediately if the dressing or site appears compromised .The following should be documented in the resident's medical record: a. Date, time, type of dressing, and reason for dressing change . Resident #1 had diagnoses that included s/p amputation of toes on left foot and PICC line in upper right arm. A 'Physician's Order', dated March 2024, read in parts, .Daptomycin 500 mg vial 500 mg via IV every 24 hours *Stop date: 03/11/24* .Cefepime 2 GM injection 2 g via…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 record review and interview, the facility failed to ensure medication was administered as ordered for one (#3) of one resident reviewed for medications being given as ordered. The administrator identified 31 residents resided in the facility. Findings: An 'Administering Medications' policy, revised December 2022, read in parts, .3. Medications must be administered in accordance with orders . Resident #3 had diagnoses that included multiple sclerosis, insomnia, and abnormal weight loss. A 'Hospital Discharge Summary', dated 04/07/24 - 04/12/24, read in parts, .temazepam 15 MG capsule .take 1 capsule (15 mg) by mouth nightly as needed for sleep . An April 2024 MAR, read in part, temazepam 15 mg capsule give 1 capsule by mouth every hs ., and documented medication was given at 12 a.m. on 04/12/24, 04/13/24, 04/14/24, and 04/15/24. On 04/15/24 at 12:00 p.m., LPN #1 was asked to review the order for temazepam on Resident #3's hospital discharge paperwork and on their April 2024 MAR. After reviewing the documents LPN #1 stated they had transcribed the order incorrectly. On…
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 · E2023-07-06 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident with a new diagnosis of mental illness was referred to OHCA for evaluation and determination of specialized services for three (#6, 10, and #14) of three sampled residents reviewed for PASARR. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 15 residents with psychiatric diagnoses. Findings: A Department of Human Services Office of Legislative Relations policy, dated 11/14/07, documented the nursing facility's routine resident assessment will identify those individuals previously undiagnosed with mental illness which must be referred to the LOCEU. 1. Resident #6 had diagnoses which included schizophrenia. A Level I PASRR screen, dated 02/21/22, documented Resident #6 had no mental illness. A MRR, dated 03/21/23, documented Resident #6 had a new diagnoses of schizophrenia. There was no documentation in Resident #6's medical record a referral was made to OHCA after the new diagnoses of mental illness. 2. Resident #14 level I screen, dated 01/29/21, documented no mental…
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 before2023-07-06 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 accurate records medication allergies for two (#6 and #14) of five sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 30 residents resided in the facility. Findings: A Charting and Documentation policy, revised July 2017, read in part, .Documentation in the medical record will be .accurate . 1. Resident #6's chart was observed to have a red Allergies sticker on the front of it. The sticker documented penicillin and Lortab. A care plan, start date 03/13/23, documented Resident #6 had allergies to hydrocodone/acetaminophen and penicillin. Resident #6's physician orders, dated 06/09/23, documented no allergies. On 07/05/23 at 8:27 a.m., the DON was asked how they determined the residents' medication allergies. They stated by admission physician orders. The DON was asked if Resident #6 had any allergies. They were observed to look at his allergies sticker and stated lortab and penicillin. The DON was asked what Resident #6's physician's 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.
- Potential for harm · D2023-07-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 provide a resident call system that would allow the resident to call for staff assistance for one (#5) of 24 sampled residents reviewed for accessibility of call lights. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 30 residents resided in the facility. Findings: A Bedrooms policy, revised May 2022, read in part, .All resident rooms are equipped with a resident call system that allows residents to call staff for staff assistance . On 07/03/23 at 10:21 a.m., Res #5 was observed lying on their bed. No call light button was observed within their reach. The call light system hub with two attachment ports was noted on the wall between beds A and B. One port contained a cord that extended over to bed A. It was draped around bed A's bedrail with a call button at the end. There was no cord connected to the second port. Res #5 was asked how they would call the nurse if they needed assistance. They stated they would pull the string. Res #5 was asked where their call light button…
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 · D2023-07-06 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident with evidence of mental illness was referred to OHCA for evaluation and determination of specialized services for one (#24) of four sampled residents reviewed for PASRR. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 15 residents with psychiatric diagnoses. Findings: A Department of Human Services Office of Legislative Relations policy, dated 11/14/07, documented the nursing facility's routine resident assessment will identify those individuals previously undiagnosed with mental illness which must be referred to the LOCEU. Resident #24 had diagnoses which included post-traumatic stress disorder. A level I PASRR screen, dated 08/04/21, documented Resident #24 had evidence of serious mental illness. There was no documentation in Resident #24's medical record a referral was made to OHCA for a level II PASRR for diagnoses of mental illness nor that a level II PASRR had been completed. On 07/05/23 at 10:30 a.m., the DON confirmed that, on admission, a resident who answered…
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 before2023-07-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to update the person-centered care plan for existing and newly developed wounds for one (#13) of 12 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 07/03/23, documented 30 residents resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised December 2016, read in part, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Resident #13 had diagnoses that included paraplegia and diabetes type 2. Wound/Skin notes, dated 01/11/23 through 03/13/23, documented Resident #13 had two stage 2 wounds on their right buttock. No documentation of these wounds were present on Res #13's Care Plan. Wound/Skin note, dated 03/21/23, documented the two stage 2 wounds on Resident #13's right buttock had merged together into one wound. No update was made to Resident #13's Care Plan. Wound/Skin note, dated 05/30/23, documented Resident #13 had developed a new,…
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 before2023-07-06 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to assess residents for the use of bed rails, educate residents and/or representatives on the risks and benefits of bed rails, and obtain an informed consent prior to the installation of bed rails for one (#28) of one sampled resident reviewed for bed rails. The DON identified one resident had bed rails at the top and bottom of their bed. Findings: A Bed Safety and Bed Rails policy, dated August 2022, read in part, .The use of bed rails is prohibited unless the criteria for use of bed rails have been met .The resident's sleeping environment is evaluated by the interdisciplinary team .Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment .The use of bed rails .is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent . Resident #28 was admitted…
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 · D2023-07-06 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview,the facility failed to ensure physician orders lab was collected for one (#6) of five sampled residents reviewed for labs. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 30 residents resided in the facility. Findings: An undated Lab and Diagnostic Test policy, documented the physician would order diagnostic testing based on the resident's monitoring needs and staff would process and arrange for the tests. Resident #6 had diagnoses which included DM. A physician's order, dated 10/04/22, documented to collect a HGBA1C every three months in February, May, August, and November. There was no HGBA1C located in Resident #6's medical records. On 07/05/23 at 8:44 a.m., the DON was asked to provide the May HGBA1C lab. On 07/06/23 at 8:03 a.m., the DON stated the May HGBQ1C lab had been missed.
- Potential for harm · Dcited before2023-07-06 · 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 staff wore gloves when administrating insulin injection to one (#27) of one resident observed for insulin administration. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 30 residents resided in the facility and five residents received injections. Findings: Resident #27 had diagnosis which included type two diabetes mellitus. A Physician Orders, dated 08/31/23 documented Resident #27 was to receive nine units of Novolin R subcutaneously before meals, and 14 units of Levemir subcutaneously every morning. On 07/05/23 at 6:27 a.m., LPN #1 was observed to administer two insulin injections to Resident #27's left abdomen. The LPN was not observed to wear gloves during administration. On 07/05/23 at 6:29 a.m., LPN was asked when staff were to wear gloves. They stated, Anytime touching bodily fluids. They were asked when staff were to wear gloves during insulin injections. They stated they don't wear gloves because they weren't touching bodily fluids. On 07/05/23 at 7:39 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$33,924 in federal fines across 1 penalty.
- $33,924 — penalty dated 2024-04-15
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to 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 | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 1 of 5 | 2.4 | -1.4 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 05/08/2017 |
| TORSON, JULIE | Individual | W-2 MANAGING EMPLOYEE | — | since 04/13/2022 |
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 $290K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375485. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.