Fountain View Manor, INC
107 East Barclay, Henryetta, OK 74437 · For profit - Corporation · 119 certified beds · (918) 652-7021 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- 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
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 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 | 13.2% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.0% | 3.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.0% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 4.1% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 7.3% | 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 | 5.6% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.7% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.6% | 25.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.4% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.3% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.9% | 17.5% | 17.1% | worse |
| Short-stay residents given the seasonal flu vaccine | 95.2% | 74.1% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.71 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.32 | 2.96 | 1.80 | worse |
‡ 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 0.02 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 119 beds and averages 81.7 residents a day — about 69% occupied, or roughly 37 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.96 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 is below 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 3.05 hrs/resident/day on weekends vs 2.93 on weekdays — about the same on weekends as weekdays. RN hours go from 0.36 to 0.42 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Ecited before2026-01-20 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete criminal history background checks for 2 (LPN #1 and LPN #2) of 5 sampled employees reviewed for criminal history background checks. The administrator identified 80 residents resided in the facility. Findings: An undated Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, read in part, Screening: The facility will screen employees for a history of abuse, neglect or mistreating residents by attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.1.An undated and untitled employee list showed LPN #1 was hired on 10/08/24.A review of the employee file for LPN #1 showed no criminal history/background check results. 2. An undated and untitled employee list showed LPN #2 was hired on 06/25/25. A review of the employee file for LPN #2 showed no criminal history/background check results. On 01/14/26 at 12:34 p.m., the administrator stated they were told they did not have to do background checks on nurses.…
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 before2026-01-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to prepare food in a manner to minimize the risk of infection/cross contamination for 1 (the noon meal) of 1 meal services observed. The DM identified 80 residents received meals from the kitchen. Findings: On 01/13/26 at 12:12 p.m., a tour of the kitchen was conducted. [NAME] #1was observed to prepare the puree dessert. DA #1 was observed to carry a bucket with sanitizing water to the sink in the cooking area, beside the prep table, used to prepare puree food. DA #1 was observed to dump the contents of the bucket in the sink, then they set the bucket on the prep table beside the food processor. On 01/13/26 at 12:39 p.m., DA #1 was observed to wipe down a prep table with a rag from the sanitizing bucket. DA #1 was then observed handling food trays without washing their hands. On 01/13/26 12:45 p.m., cook #1 was observed to take a large sheet pan of burritos out of the oven using a sanitizing rag as a potholder. They were observed to prepare trays without washing hands. On 01/20/26, at 1:40 p.m., the DM stated the staff should…
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 · E2026-01-20 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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 call lights were operational and available for 14 of 14 rooms occupied by residents on the memory care unit.The DON identified 22 residents resided in the memory care unit. Findings:On 01/13/26 at 9:00 a.m., a tour of the memory care unit was conducted. On 01/13/26 at 9:01 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:02 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:03 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:04 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:05 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:06 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:07 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:08 a.m., room [ROOM NUMBER] was observed to have no call light.On 01/13/26 at 9:09 a.m., room [ROOM NUMBER] 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 · D2026-01-20 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents and/or representatives were offered the opportunity to create an advance directive for 2 (#9 and #18) of 18 sampled residents reviewed for advance directives.The DON identified 80 residents resided in the facility. Findings:1.An undated admission record showed Resident #9 admitted to the facility on [DATE].A review of electronic health records for Resident #9 showed no advance directive acknowledgment form in the record.2. An undated admission record showed Resident #18 admitted to the facility on [DATE].A review of electronic health records for Resident #18 showed no advance directive acknowledgment form in the record.On 01/14/26 at 11:33 a.m., social services #1 stated there were no advance directive acknowledgement forms in the residents' charts. Social Services #1 stated the form must have been left out of the admission packet when they made more copies.
- Potential for harm · Dcited before2026-01-20 · 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 assessments were accurate for antipsychotic medications for 1 (#18) of 18 sampled residents reviewed for resident assessments.The DON identified 80 residents resided in the facility. Findings:A physician order, dated 11/12/25, showed Resident #18's Olanzapine (an antipsychotic) was discontinued.A quarterly assessment, dated 11/25/25, showed Resident #18 had a BIMS score of 10 which showed the resident's cognition was moderately impaired for daily decision making. The assessment showed diagnoses which included dementia and depression. The assessment showed Resident #18 had received an antipsychotic medication daily during the seven day look back period.On 01/20/26 at 10:39 a.m., the DON stated the assessment was inaccurate.
- Potential for harm · D2026-01-20 · 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 date and change oxygen equipment as ordered by the physician for 1 (#55) of 1 sampled resident reviewed for oxygen use. The ADON identified five residents with orders for oxygen use. Findings: On 01/12/26 at 2:17 p.m., Resident #55 was observed lying in bed with their eyes closed. The resident had humidified oxygen in place per nasal cannula. Resident #55's nasal cannula was not dated. The humidifier bottle and storage bag taped to the oxygen machine showed was dated 11/26/25. On 01/13/26 at 10:25 a.m., Resident #55 was observed resting with their eyes closed. Resident #55 had a nasal cannula with humidified oxygen in place. The nasal cannula was not dated, and the humidifier bottle was dated 11/26/25. A storage bag was taped to the side of the oxygen machine and was dated 11/26/25. On 01/13/26 at 4:10 p.m., Resident #55 was observed lying in bed with oxygen per nasal cannula in place. The oxygen tubing was not dated and the humidifier bottle and a storage bag hanging from the oxygen machine was dated…
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 before2026-01-20 · 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 implement enhanced barrier precautions during wound care for 2 (#49 and #75) of 3 sampled residents reviewed for wound care.The administrator identified three residents with open wounds and three residents with urinary catheters for the use of enhanced barrier precautions. Findings: 1. On 01/14/26 at 9:05 a.m., LPN #3 was observed to provide wound care for Resident #49. LPN #3 gathered the supplies and entered the room of Resident #49. LPN #3 was observed to don a pair of gloves, but was not observed to don a gown. An undated facility policy titled Enhanced Barrier Precautions, read in part, PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Wound Care: any skin opening requiring a dressing. An annual assessment, dated 12/17/25, showed Resident #49 was severely impaired for daily decision making and had memory problems. The assessment showed the resident did not have pressure ulcers. The assessment showed Resident #49 had diagnoses which included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-04-25 · tag F0732 — widespreadPost 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 ensure posting staffing information contained the required components and was accessible to all residents. This had the potential to affect 73 of 73 residents. The administrator identified 73 residents who resided in the facility. Findings: On 04/22/24 at 8:55 a.m., posted staffing information was observed on a white board at the nursing station. The facility name and staffing hours were not documented. On 04/23/24 at 9:00 a.m., posted staffing information was observed on a white board at the nursing station. The facility name and staffing hours were not documented. On 04/24/24 at 1:30 p.m., there was no posted staffing information in the Alzheimer's unit. On 04/25/23 at 9:30 a.m., the DON reported there was no posted staffing information in the Alzheimer's unit and reported anyone wanting to know staffing information would have to go to the central nursing station outside of the unit. The DON reported they were not aware of the requirements for posted staffing information.
- Potential for harm · Ecited before2024-04-25 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facilty failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 9 (CNA #1, 2 and #3, Dietary Aides #1 and #2, SS Assistant #1, Activity Assistant #1 and #2 and Housekeeper #1) of 65 employees hired between 2016 and 2024. The administrator identified 73 residents who resided in the facility. Findings: The Abuse, Neglect, and Exploitation Policy, undated, read in part, .Screening: It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include .criminal background checks .A criminal background check will be conducted on all prospective employees . The Employees roster, undated, documented the following: a. CNA #1 was hired on 02/15/24 b. CNA #2 was hired on 03/27/19 c. CNA #3 was hired on 03/08/17 d. Dietary Aide #1 was hired on 01/23/24 e. Dietary Aide #2 was hired on 09/27/23 f. SS Assistant #1 was hired on 11/22/22 g. Activity Assistant #1 was hired on 02/02/23 h. Activity Assistant #2 was hired on 03/02/23 i. Housekeeper #1…
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 before2024-04-25 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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 coding of MDS assessments: a. for diuretic use for one (#23) of 19 sampled residents; b. for falls for two (#10 and #23) of 19 sampled residents; c. for insulin use for one (#9) of 19 sampled residents; and d. for antipsychotic medication use for one (#17) of 19 sampled residents whose MDS assessments were reviewed. The administrator identified 73 residents who resided in the facility. Findings: 1. Res #23 had diagnoses which included chronic obstructive pulmonary disease, chronic pain, and anxiety. An admission MDS assessment, dated 04/04/24, documented Res #23 was cognitively intact, received a diuretic, and had two falls with no injury during the review period. No documentation of an order for a diuretic was observed in Res #23's medical record. The medical record documented one fall without injury during the review period. On 04/25/24 at 10:09 a.m., MDS coordinator #1 stated Res #23 had not received a diuretic. They stated the MDS assessment was coded in error. On 04/25/24 at 12:17 p.m., MDS coordinator…
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 18 citations
- Potential for harm · E2024-04-25 · 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 — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure multidose vials were dated upon opening. The Administator reported 73 residents resided in the facility. Findings: On 04/25/24 at 10:08 a.m., the north hall medication refridgerator was observed and the following medications were found. 1 vial house stock Tuberculin Purified Protein was opened and not dated, 2 vials of multi use Influenza vaccine were opened and not dated. On 04/25/24 at 10:30 a.m., the ADON reported the bottles should have been dated when opened.
- Potential for harm · E2024-04-25 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for two (#51 and #57) of two residents reviewed for accident hazards. The DON identified four residents whose beds were equipped with a bed rail of any type. Findings: A bedrail policy, dated 2023, read in part, .The facility will ensure that the resident's bed is appropriate and that bed rails are correctly installed and maintained, following manufacturers' recommendations and specifications . 1. Res #51 had diagnoses which included urinary incontinence, chronic pain, and morbid obesity. A care plan, dated 04/09/24, documented Res #51 was at risk for self-care deficit related to disease process. The care plan documented use of left half rail to assist with turning. A quarterly assessment, dated 04/13/24, documented the resident was moderately cognitively impaired, and dependent with ADLs and transfers. On 04/22/24 at 9:21 a.m., Res #51 was observed lying…
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 · D2024-04-25 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure residents right to personal privacy for one (#40) of one resident sampled for personal privacy. The DON reported 27 residents resided on the Alzheimer's unit. Findings: Res #40 admitted to the facility with diagnoses of hypertension, dementia, and thyroid disorder. On 04/22/24 at 9:36 a.m., resident #40 complained of wandering residents coming into their room. On 04/24/24 at 10:10 a.m., an observation of the Alzheimer's unit was conducted. Residents were observed going in and out of several rooms. An unknown resident was observed sleeping on a bed in an unoccupied room. No staff was observed providing supervision at this time. On 04/24/24 at 10:12 a.m., CNA #4 was observed entering the unit with a resident. CNA #4 reported she was giving the resident a shower. This surveyor asked how many staff were assigned to the unit. They reported them and another CNA who was performing care for a resident. The CNA #4 was asked if residents always wander in and out of other resident rooms. They reported they try to redirect them…
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 · D2024-04-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for one (#51) of one resident reviewed for bathing. The administrator identified 73 residents who resided in the facility. Findings: Res #51 had diagnoses which included urinary incontinence and morbid obesity. A significant change assessment, dated 01/12/24, documented the resident was moderately cognitively impaired and required substantial assistance with bathing. A care plan, dated 04/09/24, documented Res #51 was at risk for self care deficit related to disease process. The care plan documented the resident's ADL needs will be completed by staff daily. A facility shower schedule documented Res #51 was to receive a bath/shower on Tuesday, Thursday, and Saturday weekly. The February 2024 electronic bathing record documented Res #51 was bathed one out of thirteen opportunities. The record had no documentation of refusals. The March 2024 electronic bathing record documented Res #51 was bathed six out of twelve opportunities. The record documented one refusal. 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 · D2024-04-25 · 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 observation, record review, and interview, the facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side rails for two (#51 and #57) of two residents reviewed for accident hazards. The DON identified four residents whose beds were equipped with a bed rail of any type. Findings: A bedrail policy, dated 2023, read in part, .The facility will ensure that before installing bed rails, the facility has attempted to use alternatives. If the attempted alternatives were not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails, which will include a review of risks, including entrapment . 1. Res #51 had diagnoses which included urinary incontinence, chronic pain, and morbid obesity. A care plan, dated 04/09/24, documented Res #51 was at risk for self-care deficit related to disease process. The care plan documented use of left half rail to assist with turning. A quarterly assessment, dated 04/13/24, documented the resident was moderately cognitively impaired, and dependent with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-25 · 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 ensure residents did not receive a psychotropic medication, unless for a specific diagnosis condition for one (#33) of five residents reviewed for unnecessary medications. The Administrator reported 73 residents resided in the facility. Findings: Res #33 admitted to the facility with diagnoses of dementia, sleep disorder, and hypertension. A physician order, dated 03/27/24, documented Olanzapine 5mg every evening for dementia. On 04/25/24 at 10:53 a.m., the DON reported dementia is no an appropriate diagnosis for Olanzapine and should be changed.
- Potential for harm · Fcited before2023-03-10 · 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 — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store, prepare, and serve food in a sanitary manner. The Resident Census and Conditions of Residents form documented 79 residents residing in the facility received their meals from the kitchen. Findings: On 03/06/23 from 9:20 a.m. through 10:15 a.m., the kitchen initial tour was conducted. The refrigerator in the back room contained a gallon and a quart sized bag of spinach which appeared discolored, brown, and soggy. The bags were not dated. An additional gallon sized bag of celery, dated 02/16/23 was appeared to be discolored, dark brown, and soggy. The refrigerator in the kitchen area was observed to have an undated large bag of shredded lettuce mix which appeared discolored and soggy. The refrigerator also held a large undated bag of bow tie noodles which appeared slimy. The kitchen area was observed to be dirty with trash, foil pieces, food, and wet with puddles of water noted on the floor in front of the stove and prep area. At that time, the DA and cook #1 disposed of the discolored, soggy, lettuce, spinach, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure completed resident assessments were transmitted to CMS within 14 days of completion for three (#29, 40, and #51) of three residents reviewed for resident assessments. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. An annual assessment for Res #29 had an ARD date of 02/18/23. On 03/09/23 at 9:30 a.m., the DON/MDS coordinator stated the MDS had been completed but not locked. She stated the MDS could not be transmitted if it was not locked. On 03/09/23 at 11:24 a.m., the EHR representative stated the survey team was unable to view the MDS dated [DATE] as it had just been submitted to CMS by the administrator. 2. A quarterly assessment for Res #51, dated 01/07/23, was unable to be viewed and had a question mark in the acceptance box of the EHR. A transmittal report, printed on 03/09/23, showed this assessment had been submitted more than 14 days from completion. 3. A quarterly…
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 before2023-03-10 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure assessments accurately reflected the residents' current status for seven (#5, 45, 53, 57, 60, and #70) of 23 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. Res #53 had diagnoses which included vascular dementia without behavioral disturbances and major depressive disorder. A physician order, dated 01/11/23, documented an order for lorazepam (an antianxiety medication) for a diagnosis of major depressive disorder. A quarterly assessment, dated 01/27/23, documented the resident received antipsychotic, antidepressant, and opioid medication daily during the seven day assessment period but did not document the resident was receiving an antianxiety medication. On 03/28/23 at 2:00 p.m., the DON confirmed she had not coded for antianxiety medication on the quarterly assessment when the resident was receiving lorazapam. 2. Res #60…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: a. include PASRR II evaluations in the comprehensive assessments and incorporate the recommendations into the residents' care plans for two (#45 and #48) and b. refer residents with a new serious mental disorder to the state for a level II PASRR evaluation for one (#57) of three residents sampled for PASRR screening and evaluations. The SSD identified seven residents with PASRR II evaluations. Findings: 1. Res #45's annual MDS, dated [DATE], documented the resident was not currently considered by the state level II PASRR process to have a serious mental illness. The assessment documented the resident had a diagnoses of schizophrenia. The resident's most recent PASRR II evaluation, dated 11/21/22, documented the resident had a serious mental illness as defined by CMS. The evaluation documented the following recommendations: a. Psychiatric: Please ensure proper DSM-5 diagnosis and accordingly a standard of care treatment plan that factors in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-10 · 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 record review, observation, and interview, the facility failed to ensure comprehensive care plans addressed residents' care needs for four (#25, 29, 45, and #57) of 23 residents whose records were reviewed. The facility failed to develop care plans to address: a. pressure ulcers for Res #25. b. wandering and behaviors for Res #29. c. dental status for Res #45. d. anticoagulant use for Res #57. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. An undated facility policy, titled WOUND CARE/TREATMENT GUIDELINES read in part, .N. The care plan should reflect the current status of the wound and appropriate goals. Res #25 had diagnoses which included disorder of the skin and dementia. A care plan, dated 10/06/22, did not document a care plan for the prevention or treatment of pressure ulcers. An annual assessment, dated 01/04/23, documented Res #25 was severely impaired in cognition and required extensive to total assistance with most ADLs. 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 · E2023-03-10 · tag F0657 — failed to keep the care plan current — patternDevelop 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, observation, and interview, the facility failed to ensure resident care plans were updated to meet their care needs for three (#29, 53, and #70) of 23 residents whose records were reviewed. The facility failed to update the residents' care plans for: a. steps to prevent the reoccurrence of falls for Res #53 and Res #70. b. use of psychotropic medications for Res #29. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. Res #29 had diagnoses which included dementia with behavioral disturbance, psychotic disorder with delusions, restlessness and agitation, visual hallucinations, auditory hallucinations, bipolar disorder, wandering, conduct disorder, and frontotemporal dementia. A care plan, dated 02/14/23, documented the resident was at risk for side effects from routine use of Lexapro and routine trazodone. A physician order, dated 02/17/23, documented the facility was to administer paroxetine (an antidepressant medication) daily for a diagnosis of bipolar disorder. A physician order, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-10 · tag F0744 — failed to care for residents with dementia — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 residents diagnosed with dementia had care plans which addressed their individual dementia care needs for two (#29 and #46) of four residents reviewed for dementia care. The Resident Census and Conditions of Residents form documented 51 residents who lived in the facility had a dementia diagnosis. Findings: 1. Res #29 had diagnoses which included dementia with behavioral disturbance, psychotic disorder with delusions, restlessness and agitation, visual hallucinations, auditory hallucinations, bipolar disorder, wandering, conduct disorder, and frontotemporal dementia. A quarterly assessment, dated 11/20/22, documented Res #25 was severely impaired in cognitive skills for daily decision making, was independent with walking, and had behaviors directed toward others and rejection of care one to three days of the assessment period. The assessment documented the resident had hallucinations and delusions. The assessment documented the resident wandered daily. An annual assessment, dated 02/18/23, 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.
- Potential for harm · E2023-03-10 · 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, observation, and interview the facility failed to ensure the physician addressed each irregularity found by the consultant pharmacist in a timely manner for three (#29, 53, and #57) of five residents reviewed for unnecessary medications. The facility failed to ensure: a. a record of monthly medication regimen reviews were kept on file for Res #29. b. a physician provided a rational for not attempting a reduction of psychotropic medications for Res #29. c. a physician responded to a request for reduction of medications for Res #53 and Res #57. d. a policy addressing the time frames for the different steps in the process for the montly drug regimen reviews had been developed, agreed upon, and implemented. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. The administrator provided three separate policies regarding the consultant pharmacist reviews. A facility policy and procedure, titled Consultant Pharmacist and dated 10/25/17, read in part, .11. If the facility has not received any communication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-10 · 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to maintain resident records which were complete, readily accessible, and systematically organized. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. Res #29 was sampled for unnecessary medication review. The facility was unable to provide documentation of MRR reports for the months of April, July, and September of 2022, and January of 2023. On 03/09/23 at 3:16 p.m., the DON stated she could not find the missing MRRs. She stated she had contacted the consultant pharmacist and he was having computer issues and could not access them to send her copies. 2. Residents #5, 45, and 229 were sampled for the bathing task completed as scheduled. On 03/07/23, the ADON was asked to provide the bathing documentation. The documentation on the EHR could only be viewed for the last three days. The facility's bathing records for these residents were not readily available for review. On 03/09/23 at 11:53, the administrator and EHR company provided the needed bathing documentation.
- Potential for harm · Ecited before2023-03-10 · 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 record review, observation, and interview, the facility failed to maintain an infection prevention and control program to prevent the spread of infections. The facility failed to ensure: a. staff were wearing masks when their county transmission rate was high for COVID-19. b. the staff followed facility policy and standards of care while performing wound care on resident #3 and #25. The Residents Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. The CDC guidelines titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic read in parts, .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Ensure everyone is aware of recommended IPC practices in the facility .When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients . On 03/06/23, the CDC…
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 before2023-03-10 · 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, observation, and interview, the facility failed to ensure ordered medications were administered for the appropriate diagnoses for one (#46) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 42 residents received antidepressant medications. Findings: Res #46 had diagnoses which included dementia, major depressive disease, and amnesia. A physician order, dated 06/03/21, documented the facility was to administer 20 mg of citalopram hydrobromide (an antidepressant medication) tablet daily at bedtime for a diagnosis of dementia in other diseases classified elsewhere with behavioral disturbance. A quarterly assessment, dated 01/04/23, documented the resident was severely impaired in cognition and was independent to requiring limited assistance with ADLs. The assessment documented the resident received antipsychotic and antidepressant medications daily during the assessment period. On 03/09/23 at 3:11 p.m., the DON stated the diagnosis of dementia was not appropriate for citalopram. She stated 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 · D2023-03-10 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 labs as ordered by the physician for one (#29) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: Res #29 had diagnoses which included hypothyroidism. A lab report, dated 05/09/22, documented the resident's TSH level was 40.63 (reference range was documented as 0.45 - 5.33 uIU/ml). A physician order documented on the lab report ordered an increase the resident's dose of Levothyroxine (a medication used to treat hypothyroidism) to 75 mcg daily and recheck the TSH level in six weeks. A MRR, dated 08/21/22, documented a TSH should have been drawn six weeks from 05/09/22 and to please address. The MRR form did not document a response. A physician order, dated 09/09/22, documented the facility was to administer Levothyroxine 75 mcg daily at 8:00 a.m., for a diagnosis of hypothyroidism. An annual assessment, dated 02/18/23, documented the resident was severely impaired in cognitive skills for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MOLET, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; GENERAL PARTNERSHIP INTEREST | 5% | since 05/01/2019 |
| MOLET, DONNA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 17% | since 05/10/2019 |
| MUNHOLLAND, JENNIFER | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 67% | since 10/01/2018 |
| BENEDICT, DAYNA | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2023 |
| MCGUIRE, ANGELA | Individual | ADP OF THE SNF | — | since 01/01/2022 |
CMS files one row per role, so the 12 rows in the source record cover these 5 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.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
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 375462. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-20, 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.