Memorial Heights Nursing Center
1305 Southeast Adams, Idabel, OK 74745 · Non profit - Corporation · 118 certified beds · (580) 286-1065 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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
- the CMS record shows $7,443 in federal fines (most recent 2024-01-17)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (61%) 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) | 3 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 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.9% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 3.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 4.4% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 13.2% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.7% | 3.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.8% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.9% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 42.1% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.9% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.7% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.5% | 17.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.8% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 51.3% | 74.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 15.9% | 27.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 19.0% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.16 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 5.02 | 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.
40.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | 40.1%CMS range 32.2–51.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.8%CMS range 9.0–18.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.9%CMS range 5.5–15.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.45 | 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 118 beds and averages 89.2 residents a day — about 76% occupied, or roughly 29 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.15 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.89 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.85 hrs/resident/day on weekends vs 4.00 on weekdays — 4% thinner on weekends. RN hours go from 0.14 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 61% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2024-01-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident was free from abuse for one (#3) of five residents sampled for abuse. On 08/31/23 Res #3 informed the charge nurse that they were struck by CNA #3. CNA acknowledged they had slapped Res #3. The facility was in past noncompliance after having put the final measures in place to correct the deficiency on 09/05/24. The administrator identified 58 residents who resided in the facility. Findings: Res #3 had diagnoses which included major depression disorder, anxiety disorder, and cerebrovascular disease. A state reportable incident form, dated 08/31/23, documented that at 7:03 a.m. the resident informed the charge nurse they had been struck by a staff member. The form documented the charge nurse contacted the administrator and informed them Res #3 had been struck by a staff member. The form documented Res #3 had identified CNA #3 as the staff member who struck them. The form documented the charge nurse immediately assessed the resident and found no injuries. The form documented CNA #3 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 · Fcited before2026-04-15 · 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, record review, and interview, the facility failed to ensure:a. proper final cooking temperatures were monitored to check the internal temperature was safe for consumption prior to placing on the steam table for holding before meal service; andb. a log was maintained to reflect the monitoring of final cooking temperatures and holding temperatures for 1 meal service observed. The compliance officer identified 86 residents resided in the facility.Findings:A Position Description Dietary Service Manager, read in part, Assures correct procedures in preparation of food and inspects quality, temperature, and appearance of food prior to serving.On 04/14/26 at 10:32 a.m., an observation was made of peas cooking on the stove, roast beef was in the oven, rolls were rising on the counter, and rice was on the stove. On 04/14/26 at 10:35 a.m., the dietary manager was observed to prepare puree roast with a piece from the pan in the oven and the juice from the pan. There was no observation the dietary manager obtained a temperature of the roast.On 04/14/26 at 10:46 a.m., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident representatives were notified of a change in condition for 2 (#98 and #100) of 3 sampled residents reviewed for change of condition. The administrator identified 86 residents resided in the facility. Findings: An undated facility Notification of Changes policy read in part, The facility must immediately inform.The resident representative(s) when there is.A significant change in the resident's physical, mental or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). A nursing note, dated 10/05/25 at 12:58 a.m., showed Resident #98 received cardiopulmonary resuscitation at the facility and emergency medical services transported the resident to the hospital at 1:03 a.m. There was no documentation Resident #98's representative was notified of the change in condition and transfer to the hospital on [DATE]. On 04/09/26 at 6:23 p.m., LPN #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 · E2026-04-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure catheter care was performed for an indwelling catheter for 1 (#10) of 3 sampled residents reviewed for urinary catheter.The compliance officer identified 6 residents with a urinary catheter resided in the facility. Findings: An undated policy titled Incontinence, read in part, Ensure that a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. A physician order, dated 09/17/25, showed catheter to gravity. A physician order, dated 11/25/25, showed to change catheter every month. There were no orders for catheter care located in the EMR. A quarterly assessment for Resident #10, dated 12/30/25, showed the brief interview for mental status score of 13 indicating cognitively intact. The assessment showed Resident #10 required partial to moderate assistance with mobility and was dependent with toileting due to indwelling urinary catheter and ileostomy. The assessment showed a diagnosis of urinary retention and a urinary…
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 · E2026-04-15 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure before and after dialysis assessments and weights were obtained for 1 (#26) of 1 sampled resident reviewed for dialysis. The administrator identified 6 dialysis residents resided in the facility. Findings:A policy titled Dialysis, undated, read in part, The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice. Ongoing assessments of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.A physician's order, dated 01/23/26, showed assess dialysis site to right chest every day and night shift.A physician's order, dated 01/24/26, showed hemodialysis every day shift every Tuesday, Thursday, and Saturday.A physician's order, dated 01/24/26, showed weigh before and after dialysis every day shift every Tuesday, Thursday, and Saturday.An admission assessment 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.
- Potential for harm · D2026-04-15 · 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 ensure the call light was within reach for 1 (#84) of 18 sampled residents observed for call lights within reach. The administrator identified 86 residents resided in the facility. Findings: On 04/08/2026 at 10:50 a.m., Resident #84 was observed in bed. The call light was observed on the floor behind the resident's head of bed. On 04/08/26 at 11:14 a.m., CNA #6 went into Resident #84 room and picked up the call light from the floor behind the resident's head of bed. A policy titled Call Light, Use of, undated, read in part, All facility personnel must be aware of call lights at ALL times. Be sure all call lights are placed within the reach of each resident, never on the floor or bedside stand. On 04/08/26 at 10:51 a.m., Resident #84 stated they would yell out when they needed assistance. On 04/08/26 at 11:12 a.m., CNA #6 stated Resident #84 required two people for assistance with activities of daily living. They stated Resident #84 was able to use a call light. CNA #6 stated the call light was kept within…
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 · D2026-04-15 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident's discharge assessment was completed and transmitted for 1 (#74) of 18 sampled residents reviewed for assessments. The compliance officer identified 29 residents had discharged from the facility since 11/2025.Findings: Resident #74's electronic record, under the diagnoses tab, showed Resident #74 had diagnoses which included fracture of the left femur, hypertension, and edema. A Post-Discharge Plan of Care, dated 02/28/26, showed Resident #74 was discharged to home. There was no documentation a discharge resident assessment was completed. On 04/13/26 at 11:31 a.m., the DON stated the MDS coordinator was responsible for the completion of MDS assessments. On 04/13/26 at 11:40 a.m., the administrator reviewed the electronic record for Resident #74. The administrator stated the discharge assessment for Resident #74 had not been completed and should have been completed. The administrator stated ultimately, they were responsible for ensuring the MDS was completed. The administrator stated they were the RN who…
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 before2026-04-15 · 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
Based on record review and interview, the facility failed to ensure a care plan was developed to address hospice services for 1 (#60) of 1 sampled resident reviewed for hospice services. The compliance office identified 11 residents who received hospice services resided in the facility.Findings:An undated facility policy titled Comprehensive Care Plan, read in part, Each resident will have a person-centered comprehensive care plan developed and implemented to meet [their] preferences and goals and address the resident's medical, physical, mental and psychosocial needs.A hospice physician's order, revised 07/07/25, showed Resident #60 started hospice on 04/17/25.Resident #60's quarterly assessment, dated 01/18/26, showed Resident #60 had a diagnosis of chronic obstructive pulmonary disease and received hospice services.Resident #60's care plan, revised on 01/30/26, did not address hospice services.On 04/15/26 at 11:48 a.m., the DON stated Resident #60's care plan did not include hospice interventions.On 04/15/26 at 11:53 a.m., the DON stated Resident #60 started hospice services 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 · D2026-04-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, record review, and interview, the facility failed to ensure medication was stored separate from personal food and drinks items for 2 of 2 refrigerators observed in the medication room. The DON identified the facility had one medication room. Findings: On 04/13/26 at 2:25 p.m., an observation of the medication room was completed. A small refrigerator was observed containing tuberculin medication, containers of yogurt, two half empty bottles of soda drinks, two bottles of water with one a fourth empty. A second small refrigerator was observed containing insulin bottles, insulin pens, an ice cream sandwich, and a packaged roast beef and cheddar sandwich. An undated facility policy titled Storage of Medications, read in part, Medications must be stored separately from food and must be properly labeled. On 04/13/26 at 2:37 p.m., the DON stated the food and drink items belonged to staff and should not be stored in the medication refrigerators.
- Potential for harm · F2025-06-12 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 an effective pest management program was maintained during daily observations.The administrator identified 78 residents resided in the facility.Findings:1. On 06/08/25 at 4:03 p.m., rodent feces were observed in room [ROOM NUMBER]B's bedside dresser middle drawer. On 06/08/25 at 4:50 p.m., the door in dining room going out behind the facility was observed to have had gaps at the top and along the bottom of the door large enough for flies and rodents to access the facility. Mouse droppings were observed along the wall in the dining room near the back door and flies were all over the facility landing on the glass, residents sitting nearby, and the staff. On 06/10/25 at 12:15 p.m., flies were observed in kitchen landing on a spout of clean and empty pitchers, food prep tables, foil covering food, and clean utensils. Mice droppings were observed under the food prep tables and behind the stove along the external walls. An irregularly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-12 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure:a. prn medication was limited to 14 days for 1 (#36) of 5 residents sampled for prn medications; andb. failed to ensure an order for a gradual dose reduction for a psychotropic medication was initiated for 1(#2) of 5 residents sampled for gradual dose reductions of psychotropic medications. The Administrator identified 54 resident received psychotropic medications from the facility and all residents received other medications from the facility.Based on observation, record review, and interview, the facility failed to ensure: a) an order for a gradual dose reduction for a psychotropic medication was initiated for 1 (#2) of 5 sampled residents reviewed for physician orders for gradual dose reductions of psychotropic medications, and b) an as needed psychotropic medication order was limited to 14 days for 1 (#36) of 5 sampled residents reviewed for the use of psychotropic medications. The administrator identified 54 residents received psychotropic…
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 17 citations
- Potential for harm · E2025-06-12 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to employ adequate kitchen staff to effectively maintain a sanitary kitchen environment.The Administrator identified 78 residents who ate meals prepared in the kitchen.Based on observation and interview, the facility failed to employ kitchen staff to effectively maintain a sanitary kitchen environment.The administrator identified 78 residents ate meals prepared in the kitchen.Findings:On 06/08/25 at 1:45 p.m., the following observations were made in the kitchen:a. baseboards were covered in a greasy film with dust and debris,b. the floors under the food prep tables, counters, sinks, storage racks, and behind the refrigerators, stove, and fryer were covered in a thick film of grease with dirt, grime, and mice droppings,c. the top of the refrigerators/freezers was covered in grease, dust, and grime,d. there was grease, dust, and grime present on lower shelving and wheels/casters on shelving and food prep tables,e. there was an irregularly shaped hole in the wall beside one refrigerator and just above the baseboard. The hole 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 · Ecited before2025-06-12 · 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 maintain a clean and sanitary kitchen environment during two of two kitchen observations. The administrator identified 78 residents ate meals prepared in the kitchen.Findings:On 06/08/25 at 1:45 p.m., the following observations were made in the kitchen:a. the ice machine had a slimy looking green and brown substance along the right-side interior wall of the mechanical housing for the dish machine,b. kitchen aide #1 was observed to scrape food residue from steam table pans and resident plates, load the dirty dishes into the dish machine, then walk over to the clean side of the dish machine, remove and stack clean drinking cups, plates, pans, and covers onto drying racks without sanitizing their hands and changing gloves, c. baseboards were covered in a greasy film with dust and debris, d. the floors under the food prep tables, counters, sinks, storage racks, and behind the refrigerators, stove, and fryer were covered in a thick film of grease with dirt, grime, and mice droppings, e. the top of the refrigerators/freezers 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 · D2025-06-12 · tag F0641 — isolatedEnsure 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 observation, record review, and interview, the facility failed to ensure resident assessments were accurate for 1 (#2) of 18 sampled residents reviewed for accurate assessments.The administrator identified 78 residents resided in the facility.Findings:On 06/08/25 at 3:26 p.m., Resident #2 was observed in bed and their tongue was thrusting repeatedly from their mouth while watching television. The resident was observed to be edentulous (no natural teeth or tooth fragments). The facility's undated policy Resident Assessment, read in part, This facility conducts and periodically a comprehensive, accurate, standardized reproducible assessment of each residents functional capacity .Each assessment accurately reflects the residents status. Resident #2's admission record, showed they were admitted on [DATE] with diagnoses which included bipolar disorder, schizophrenia, Alzheimer's, and major depression. Resident #2's annual comprehensive MDS assessment, dated 11/21/24, showed the residents cognition was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-12 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 ensure the physician was notified of a change in the condition of a wound for 1 (#1) of 4 sampled residents reviewed for wounds. The administrator reported the facility census was 86. Findings: An undated Notification of Changes policy, read in part, The facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his/her authority, the resident representative(s) when there is .A significant change in the resident's physical, mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). Resident #1 had diagnoses which included a displaced fracture of the left tibia and heart failure. A physician's order, dated 01/18/25, showed Resident #1 was to receive wound care to the sacral area three times a week on Tuesday, Thursday, and Saturday. A nurse's note, dated 01/18/25 at 9:33 p.m., showed Resident #1 had a small open sore to the right buttock. A nurse's note, dated 01/19/25…
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 · Dcited before2025-02-12 · 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 enhanced barrier precautions were implemented for 1 (#3) of 3 sampled residents reviewed for pressure ulcers. The administrator identified four residents with pressure ulcers. Findings: An undated Enhanced Barrier Precautions policy, read in part, Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] beyond situations in which exposure to blood and body fluids is anticipated. These precautions refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multidrug-resistan organism] to staff hands. High-contact resident care activities include .Wound care: any skin opening requiring a dressing. Resident #3 had diagnoses which included pressure ulcer of sacral region stage four. A physician's order, dated 01/31/25, showed Resident #3 was to receive a dressing change twice a day and as needed for the wound on their sacrum. On 02/12/25 at 9:30 a.m., LPN #1 was observed providing wound care to Resident #3 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 · E2025-01-23 · 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 implement their abuse policy for three (#1, 2, and #4) of four sampled residents reviewed for abuse. The administrator identified 83 residents who resided in the facility. Findings: A policy titled Allegations of Abuse, Neglect, Exploitation or Mistreatment, read in parts All alleged violations involving abuse, neglect, exploitation or mistreatment, .are reported immediately, but not later than 2 hours after the allegation is made .to the Administrator of this facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .All alleged violations, whether oral or in writing, must be immediately reported to the Administrator of this facility .The results of all investigations are reported to the Administrator or his/her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-23 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure all allegations of abuse were reported immediately to the state agency, but no later than two hours after the allegation was made for three (#1, 2, and #4) of four sampled residents reviewed for abuse. The administrator identified 83 residents who resided in the facility. Findings: A policy titled Allegations of Abuse, Neglect, Exploitation or Mistreatment, read in parts All alleged violations involving abuse, neglect, exploitation or mistreatment, .are reported immediately, but not later than 2 hours after the allegation is made .to the Administrator of this facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .All alleged violations, whether oral or in writing, must be immediately reported to the Administrator of this facility .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-23 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to thoroughly investigate allegations of abuse for three (#1, 2, and #4) of four sampled residents reviewed for abuse. The administrator identified 83 residents who resided in the facility. Findings: A policy titled Allegations of Abuse, Neglect, Exploitation or Mistreatment, read in parts All alleged violations involving abuse, neglect, exploitation or mistreatment, .All alleged violations, whether oral or in writing, must be immediately reported to the Administrator of this facility .The results of all investigations are reported to the Administrator or his/her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .Documentation that an alleged violation was thoroughly investigated will be recorded and maintained .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 1. Resident #1 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 · E2024-02-01 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure physician orders were obtained for code status for four (#2, 23, 27, and #35) of six sampled residents reviewed for code status. The administrator identified 58 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included CKD, HTN, presence if cardiac pace maker, diabetes mellitus, hypothyroidism, and atrial fibrillation. An Advance Directive/DNR Information Acknowledgement form, dated [DATE], documented the resident wished to have CPR. There was no physician order for the resident's code status. 2. Res #23 had diagnoses which included HTN, heart disease ESRD, GERD, depression, vitamin D deficiency, and diabetes mellitus. An Advance Directive/DNR Information Acknowledgement form, dated [DATE], documented the resident wished to have CPR. There was no physician order for the resident's code status. 3. Res #27 had diagnoses which included pain, heart disease, major depressive disorder, anxiety disorder, COPD, RA, systemic…
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 · E2024-02-01 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure baseline care plans were developed within 48 hours of admission for two (#4 and #23) of 15 sampled residents reviewed for care plans. The administrator identified 58 residents who resided in the facility. Findings: 1. Resident #4 was admitted on [DATE] with diagnoses which included arthrosclerosis, secondary hypertension, chronic obstructive pulmonary disease, diabetes type II, gastroesophageal reflux disease, and Parkinson's disease. There was no documentation in the clinical record a baseline care plan had been completed. On 01/31/24 at 12:12 p.m., the administrator stated the base line care plan had not been completed. 2. Resident #23 was admitted on [DATE] with diagnoses which included end stage renal disease, disorders of the brain, cerebral infarction, diabetes, HTN, Charcot's joint, left ankle and foot, and CAD. On 01/31/24 at 11:51 a.m., the administrator was asked for Res #35's base line care plan. They stated the baseline care plan…
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 · E2024-02-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure bed rails were assessed for risk of entrapment, reviewed the risks and benefits of the bed rails with the resident or resident representative, or obtained informed consent prior to installation of the bedrail for four (#8, 27, 35, and #44) of four residents assessed for accident hazards. The administrator identified 29 residents had bed rails. Findings: An undated Bed Rail policy, read in parts, .If a bed or side rail is used, the facility must .Assess the resident for risk of entrapment from bed rails prior to installation .Review the risks and benefits of bed rail with the resident or resident representative and obtain informed consent prior to installation .After the installation of bed rails, it is expected .Ongoing assessment to ensure that the bed rail is used to meet the resident's needs .Definitions .Bed rails .are not limited to .side rails, bed side rails and safety rails and .Grab bars and assist bars . 1. Res #35 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-01 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure side effect monitoring was conducted for the use of psychotropic medications for two (#24 and #31) of five sampled residents reviewed for unnecessary medications. The corporate compliance officer identified 49 residents who had orders for psychotropic medications. Findings: 1. Res #24 had diagnoses which included anxiety and insomnia. A physician order, dated 09/23/22, documented bupropion HCL (an antidepressant) tablet 100 mg. Give 100 mg by mouth two times a day. A physician order, dated 10/21/22, documented trazadone HCL (an antidepressant) tablet 100 mg. Give one tablet by mouth every night shift. A physician order, dated 10/03/23, documented Zoloft (an antidepressant) oral tablet. Give 75 mg by mouth at bedtime. There was no documentation side effects were being monitored for the use of antidepressant medications. On 01/31/24 at 12:18 p.m., the administrator was asked if there was documentation the resident was being monitored for side effects for the use of antidepressant medications. On 01/31/24 at 1:03 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-01 · 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 ensure the kitchen was maintained to promote food safety and sanitation. The corporate compliance officer identified 58 residents received services from the kitchen. Findings: On 01/29/24 at 11:02 a.m., a tour of the kitchen was conducted. The following observations were made. a. the metal on the spray nozzle hose located on the garbage disposal sink was torn and the metal was exposed, b. water was leaking from the piping below the dish machine into containers stored on the floor. Standing water was in the containers, c. there was an accumulation of brown and black residue on the floor and the walls in the dish wash area. There was a cockroach crawling on the wall below the dish machine, d. there was black tape on the bottom of the garbage disposal sink in the dish wash area. The sink was not easy to clean, e. the gaskets were torn/split on the doors to the True three door reach in deli cooler, f. there was a plate of raw beef stored on the shelf above carrots, tomatoes, and cabbage in the True three door reach in deli…
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 · E2024-02-01 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to assess a resident for an infection using standardized tools and criteria for the initiation of an antibiotic for one (#31) of five sampled residents reviewed for unnecessary medications. The administrator identified 58 residents resided in the facility. Findings: An undated Antimicrobial Stewardship policy and procedure manual, read in parts, .Communication of Resident Condition and Treatment with Antimicrobial Orders .When the facility staff suspects a resident has an infection, the nurse should perform and appropriately document a comprehensive assessment if the resident using established and accepted assessment protocols. This assessment will determine if the resident's status meets minimum criteria for initiating antibiotics . Res #31 had diagnoses which included URI and ear infection. A physician order, dated 12/01/23, documented amoxicillin-potassium clavulante (an antibiotic) oral tablet 875-125 mg. Give one tablet by mouth two times a day for 10 days. There was no documentation the resident was assessed related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to fully develop a comprehensive care plan for one (#24) of 19 sampled residents reviewed for care plans. The administrator identified 58 residents resided in the facility. Findings: Res #24 had diagnoses which included anxiety and insomnia. A comprehensive resident assessment, dated 12/28/23, documented on the CAA summary cognitive loss/dementia and behavioral symptoms were care plan decisions. There was no documentation cognitive loss/dementia and behavioral symptoms were developed on the care plan. On 01/31/24 at 12:18 p.m., the administrator was made aware the CAA's on the resident's comprehensive assessment documented cognitive loss/dementia and behavioral symptoms were care plan decisions. They were asked if the care plan was developed to include those care areas. On 01/31/24 at 1:03 p.m., the administrator stated the care plan was not developed for cognitive loss/dementia and behavioral symptoms.
- Potential for harm · Dcited before2024-02-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to follow an infection control program during wound care for one (#35) of two sampled residents observed for wound care. The administrator identified eight residents who had wounds in the facility. Findings: 1. On 01/29/24 at 2:41 p.m. and 01/30/24 at 9:25 a.m., a suction machine canister was observed in room [ROOM NUMBER] on a bedside table with 400 ml of fluid and suctioned secretions in the canister. On 01/30/24 at 2:14 p.m., CNA #2 stated the resident who resided in room [ROOM NUMBER] had passed away on 01/27/24. On 01/30/24 at 4:20 p.m. and 01/31/24 at 8:40 a.m., a suction machine canister was observed in room [ROOM NUMBER] on a bedside table with 400 ml of fluid with suctioned secretions in the canister. On 01/31/24 at 10:40 a.m., The DON was asked who would be responsible for removing and cleaning a suction machine after a resident had passed away. They stated the nurse on duty would be responsible for cleaning and removing a suction machine after a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-17 · 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 record review and interview the facility failed to protect the resident's right to personal privacy for one (#1) of five residents sampled for for privacy. NA trainee #1 posted a video of a resident with an animated dog filter on a social media platform. The facility had put measures in place to correct the deficiency immediately on 09/24/23 and 09/25/23. The administrator identified 58 residents resided in the facility. Findings: A facility policy, titled, Web Blogging Policy, read in part, Employees are prohibited from engaging in web logging or blogging during working time .This includes browsing pages, liking posts, making posts, commenting, posting pictures etc . Res #1 had diagnoses which included dementia with behavior disturbance, cognitive communication deficit, transient cerebral ischemic attack, and frontotemporal neurocognitive disorder. An initial incident report, dated 09/24/23, documented NA trainee #1 posted a video of Res #1 with an animated dog filter on a social media platform. The report documented CNA #1 was also present during filming the of the video.…
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
$7,443 in federal fines across 1 penalty.
- $7,443 — penalty dated 2024-01-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GREYSTONE FUNDING COMPANY LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | since 12/30/2021 |
| TNO HOLDINGS, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | since 11/30/2021 |
| BARTON, BLAINE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 03/15/2023 |
| BLUE, RANDALL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/15/2023 |
| SALYER, THOMAS | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 03/15/2023 |
| SANFORD, ANDREW | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/15/2023 |
| DARBY, JAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 02/05/2025 |
| BAUCOM, KATHY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/15/2023 |
| BOK FINANCIAL CORP | Organization | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | since 04/11/2025 |
| FORVIS MAZARS LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/09/2023 |
| NUTRITION MANAGEMENT SERVICES INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2013 |
| HERMANCE, TERRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/22/2022 |
| HUGHES, LANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/25/2020 |
| JOHNSON, MILLISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2025 |
| 1305 SE ADAMS LLC | Organization | ADP OF THE SNF | since 12/31/2021 |
| BOKF,NA | Organization | ADP OF THE SNF | since 11/16/2021 |
| CANTRELL, MADISON | Individual | ADP OF THE SNF | since 04/15/2014 |
| KNAPP, THOMAS | Individual | ADP OF THE SNF | since 09/11/2021 |
| MOORE, JENNIFER | Individual | ADP OF THE SNF | since 05/21/2013 |
CMS files one row per role, so the 44 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $431K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375123. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, 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.