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Mcmahon-Tomlinson Nursing Center

2007 NW 52Nd Street, Lawton, OK 73505 · Non profit - Corporation · 142 certified beds · (580) 357-3240 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse2 actual-harm citations$6,338 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $6,338 in federal fines (most recent 2025-12-16)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4008 NW Cache Rd · (580) 379-0200 · Call to confirm hours
Pharmacy
1824 NW 52nd St · (580) 355-1511 · Call to confirm hours
Grocery
6506 NW Cache Rd · (580) 536-8200 · Call to confirm hours
Park
NW Cheyenne Ave · Typically dawn to dusk
Place of worship

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 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.3%13.6%15.4%typical
Long-stay residents who lose too much weight6.7%3.3%5.4%worse
Long-stay residents with a catheter left in their bladder3.1%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection5.1%2.8%2.0%worse
Long-stay residents with depressive symptoms12.4%3.4%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%4.7%3.3%better
Long-stay residents whose ability to walk worsened9.9%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.6%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine95.6%94.6%95.3%typical
Long-stay residents with pressure ulcers3.6%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control21.4%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.2%17.5%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.6%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine87.3%74.1%79.4%typical
Short-stay residents rehospitalized after admission23.3%27.3%22.6%typical
Short-stay residents with an outpatient ER visit19.1%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.722.311.67worse
Long-stay outpatient ER visits per 1,000 resident days3.002.961.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.5% 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 541 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.5%U.S. median 51.5%
Got home and stayed home
16.3%U.S. median 10.7%
Went back to hospital
48.8%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.29hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy

Met the expected recovery: 48.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 215 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.5%CMS range 45.7–54.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF16.3%CMS range 14.1–19.010.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge41.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge25.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.5%100.0%Oct 2024–Sep 2025CMS 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 discharge93.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.2%CMS range 7.1–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.18
RN hours/ resident / day
1.23
LPN hours/ resident / day
2.65
Aide hours/ resident / day
4.05
Total nurse hours/ resident / day
0.12
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 142 beds and averages 128.7 residents a day — about 91% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.18 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.65 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 3.77 hrs/resident/day on weekends vs 4.17 on weekdays — 10% thinner on weekends. RN hours go from 0.21 to 0.12 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

2
deficiencies at the latest standard inspection (2025-12-16)
11
at the previous standard inspection (2024-04-11)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2025-12-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 wound care was provided per physician orders for 1 (#31) of 2 sampled residents reviewed for wound care.The DON identified 123 residents resided in the facility.Findings: On 12/10/25 at 10:50 a.m., Resident #31 was observed in bed. The resident had staples to a right above knee amputation site.An Abuse & Neglect policy, dated 01/02/22, read in part, Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.A care plan for Resident #31, dated 10/02/25, showed a pressure ulcer development related to immobility and a low Braden score to the right foot, right inner foot, right ankle, and back of right leg. The care plan showed the resident's pressure ulcer would show signs of healing and remain free from infection. The care plan showed to follow facility policies/protocols for the prevention/treatment of skin breakdown.Resident #31's treatment administration…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-12-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to follow physician's orders and care plans to prevent the worsening of wounds for 1 (#31) of 2 sampled residents reviewed for wound care.The DON identified 123 residents resided in the facility.Findings: On 12/10/25 at 10:50 a.m., Resident #31 was observed in bed. The resident had staples to a right above knee amputation siteA Skin Assessment and Ongoing Skin Integrity Monitoring policy, dated 03/16/24, showed comprehensive skin assessment and ongoing monitoring were performed to identify risks, prevent skin breakdown, and ensure timely interventions in accordance with professional standards. The policy showed that documentation of skin assessments should reflect the location, size, appearance, intervention implemented and resident response. A care plan for Resident #31, dated 02/23/25, showed a pressure ulcer development related to immobility and a low Braden score to the right foot, right inner foot, right ankle, and back of right leg. The care plan showed a goal for the resident's pressure ulcer would show…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-25 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed to include skin integrity for 1 (#7) of 12 sampled residents whose care plans were reviewed. The administrator identified 122 residents resided in the facility. Findings: A Care Planning - Interdisciplinary Team policy, revised 2016, read in part, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. An undated care plan for Resident #7 did not show the resident being at risk for potential/actual skin impairment. An admission assessment for Resident #7, dated 05/10/26, showed the resident had a brief interview for mental status score of 4 indicating severe cognitive impairment, dependent with toileting and hygiene, always incontinent, and was at risk for developing pressure ulcers. A nursing note for Resident #7, dated 05/27/26, read in part, Received report that [Resident #7] has skin issue upon observation noted skin abrasion to rt inner ischium measures 9.5 x .5 cm with s/s…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2026-06-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure staff implemented proper infection control practices while performing incontinent care for 2 (#10 and #11) of 2 sampled residents observed for incontinent care.The director of nursing identified 68 residents required assistance with incontinent care.Findings:1.On 06/25/26 at 1:06 p.m., CNA #1 and CNA #2 were observed to knock on Resident #10's door and ask permission to enter. CNA #1 and CNA #2 donned a gown and gloves prior to entering. CNA #1 explained they were there to provide incontinent care. CNA #1 assisted with removing the blanket and sheet from the resident. CNA #2 lowered the head of the bed and raised the bed. Each CNA assisted with pulling the resident's pajama pants below their knees. Resident #10's brief was dry. CNA #1 was observed to wipe each side of the genitalia with one wipe each and disposing of the wipe. CNA #1 used one wipe to clean the resident's indwelling catheter then disposed of the wipe. CNA #1 assisted Resident #10 to their right side. CNA #2 wiped the resident's perineal…

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

    Infection Control Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-03-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the state agency within the 2-hour required timeframe for 1 (#1) of 3 sampled residents reviewed for abuse.The DON reported the facility census was 133.Listed below are abbreviations that will be used throughout this document.ADON - Assistant Director of Nursing APS - Adult Protective ServiceBIMs score - Brief Interview for Mental StatusDON - Director of Nursing A Abuse and Neglect policy, dated 09/12/25, read in part, The facility shall immediately report allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. The admission assessment, dated 12 /05/25, showed Resident #1 was admitted to the facility on [DATE] with diagnosis of congestive heart failure. The assessment showed the residence's cognition was intact with a BIMS score of 15.A skilled assessment, dated 12/05/25, showed Resident #1 had a skin…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 an allegation of abuse was investigated to make certain residents were free from abuse for 1 (#1) of 3 sampled residents reviewed for abuse.The DON reported the facility census was 133.Listed below are abbreviations that will be used throughout this document.ADON - Assistant Director of NursingAPS - Adult Protective ServiceBIMS score - Brief Interview for Mental StatusDON - Director of NursingA Abuse and Neglect policy, dated 09/12/25, read in part, The facility shall immediately report allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. The admission assessment, dated 12 /05/25, showed Resident #1 was admitted to the facility on [DATE] with diagnosis of congestive heart failure. The assessment showed the residence's cognition was intact with a BIMS score of 15.A skilled assessment, dated 12/05/25, showed Resident #1 had a skin assessment…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-11 · tag F0641 — pattern
    Ensure 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 and interview, the facility failed to ensure the minimum data set was coded accurately for Legionella for 1 (#1) of 1 sampled discharged resident from the hospital for skilled services. The DON/IP reported one case of Legionella. Findings: Resident #1 had diagnoses which included pneumonia (unspecified), high blood pressure, and non-Alzheimer's dementia. A hospital discharge report, dated 02/17/25, showed hospital course: patient admitted for altered mental status due to pneumonia from Legionella. A Medicare-5 day MDS assessment, dated 02/21/25, did not show the diagnosis of Legionella. On 03/11/25 at 12:45 p.m., the MDS coordinator stated the resident discharged to the hospital on [DATE] and returned from the hospital on [DATE] and the Medicare-5 day care MDS assessment was completed on 02/21/25 for skilled services. They stated the skilled services completed on 03/02/25. They stated the Legionella was not incorporated into the MDS and they did not see it on the discharge report from 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-11 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to update a care plan for 1 (#1) of 1 sampled resident with a new diagnosis of Legionella. The DON/IP reported one case of Legionella. Findings: A Care Plans, Comprehensive Person-Centered policy, dated March 2022, read in part, The interdisciplinary teams reviews and updates the care plan .c. when the resident has been readmitted to the facility from a hospital stay. On 03/10/25 at 4:48 p.m., the DON/IP was asked about Resident #1's care plan related to Legionella. They stated they thought it had been resolved. They stated it was not care planned because it was already resolved.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed infection prevention and control practices to ensure identification of high risk areas to include flushing of unused outlets to prevent the spread of a waterborne illness. The DON/IP reported 118 residents resided in the facility. Findings: A Water Management Program to Reduce Legionella and other Waterborne Path[ogens], dated 03/05/25, policy, read in part, The program will identify risk factors, establish control measures, and ensure monitoring and corrective actions to reduce the risk of Legionella and other waterborne pathogens. System Assessment: Conduct a comprehensive assessment of the facility's water systems, including . *Identify high-risk areas (e.g [for example]., showers, sinks, water tanks) .Regularly check water temperature. Documentation *Maintain detailed records of: *Testing and monitoring results *Maintenance and cleaning schedules .Water management program .We will flush hot water heaters once per year, even though the hot water systems are equivalent continuously circulating pumps. The fire sprinkler…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-11 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure assessments were accurate for two (#83 and #87) of 22 sampled residents reviewed for assessments. The Administrator identified 97 residents resided in the facility. Findings: 1. Resident #83 had diagnosis which included weakness. An Alert Note, dated 03/22/24, documented Resident #83 was on the floor with a laceration to their left upper eyebrow and was sent to the hospital. An Admission assessment, dated 03/22/24, documented the resident had one non injury fall since admission. On 04/10/24 at 10:40 a.m., the DON stated they put falls under the health condition on the assessment. She stated a laceration was considered an injury. The DON was asked to review Resident #83's assessment and was asked what was coded for falls. She stated the resident had one no injury fall. The DON stated the resident had an injury from a fall on 03/22/24. She stated the assessment was not coded accurately. 2. Resident #87 had diagnosis which included sepsis. A Discharge Report, dated 01/15/24, documented Resident #87 discharged to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-11 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure interventions were added to the care plan after a fall for two residents (#38 and #41) of 20 sampled residents reviewed for care plan revisions. The DON identified 97 Residents resided in the facility. Findings: An Assessing Falls and Their Causes policy, revised 03/2018, read in part, .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls . 1. Resident #38 had diagnoses which included type 2 diabetes mellitus, urinary incontinence, and hypertensive heart disease. Resident #38's quarterly assessment dated [DATE] documented Resident 38's cognition was mildly impaired and required partial to moderate assist with transferring. On 04/08/24 at 12:39 p.m., Resident #38 was observed to have a bruised left eye. Resident #38 stated they fell from the recliner while trying to go to the toilet. A incident report dated 04/15/23, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-11 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure neurological checks were completed after unwitnessed falls for one (#41) of three sampled residents reviewed for falls. The Administrator identified 97 residents resided in the facility. The Resident Matrix documented 21 residents had falls. Findings: A Neurological Assessment policy, revised October 2010, read in part, .The purpose of this procedure is to provide guidance for neurological assessment .when following and unwitnessed fall .When assessing neurological status, always include frequent vital signs .perform neurological checks with the frequency as ordered or per falls protocol . An Assessing Falls and Their Causes policy, revised March 2018, read in part, .Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record . Resident #41 had diagnoses which included altered mental status, dementia and anxiety. Resident #41's care plan, initiated on 12/27/23, documented the resident was at high risk 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2024-04-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when 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 observation, record review and interview, the facility failed to ensure; a. oxygen tubing was labeled and dated, per the facility policy and professional standards of care, for three (#14,64, and #143) and, b. respiratory medications were administered per the standard of practice for one (#64) of three residents sampled for respiratory care. The DON identified 11 residents received oxygen services. Findings: A Departmental (Respiratory therapy) - Prevention of Infection policy, revised 11/11, read in part, .Change the oxygen cannula, and tubing every seven days, or as needed . A Physicians Order, dated 11/15/23, read in part, .Please change oxygen tubing weekly .tag tubing with date a residents name . 1. Resident #14 had diagnoses which included macular degeneration, lesion of the plantar nerve, and osteoporosis. Resident #14's comprehensive assessment, dated 03/25/24, documented Resident #14 was dependent for transferring from bed to chair and cognition was moderately impaired and used oxygen. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-11 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide 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 a. the resident assessment at the dialysis center was communicated between the dialysis center and nursing staff was in place, and b. pre- and post- dialysis assessments were completed by the facility for one #63) of one resident reviewed for dialysis. The DON stated four residents received dialysis. Findings: A Long Term Care Facility Dialysis Services Agreement dated 05/10/21, read in parts, . Dialysis Center Obligations .provide to Care Facility from time to time all appropriate information and guidance regarding the renal condition of Residents who are patients of Dialysis Center, including administration of medications, directions for handling medical and nonmedical emergencies . and the care of shunts and fistulas . An undated End-Stage Renal Disease, Care of a Resident with policy, read in parts, .Residents .will be cared for according to currently recognized standards of care .Staff .shall be trained in the care and special needs of these residents .Agreements between this facility and the contracted…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-11 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure Registered Nurse coverage was provided 8 hours per day for 7 days a week for nine (10/01/23,10/07/23,10/15/23,10/22/23,11/11/23,11/19/23,12/03/23,12/09/23, and 12/17/23 of 92 days sampled for RN coverage. The DON identified 97 Residents resided in the facility. Findings: A Departmental Supervison, Nursing policy, revised 08/2022, read in part, .A registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week . A Detail of Time documents for the following dates did not document RN coverage for 8 consecutive hours; a.10/01/23, b.10/07/23, c.10/15/23, d.10/22/23, e.11/11/23, f.11/19/23, g.12/03/23, h.12/09/23, and i. 12/17/23. On 04/11/24 at 8:58 a.m., the Administrator was asked to show RN coverage on the above dates. The Administrator stated there was no RN on those dates for 8 consecutive hours which made the facility a one star rating.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-11 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to ensure three extended release medications were not crushed for two (#6 and #23) of eight sampled residents reviewed during medication pass. A total of 39 opportunites were observed with three errors. The medication error rate was 6.94%. The Administrator identified 97 residents resided in the facility. Findings: A Crushing Medications policy, last revised April 2018, read in part, The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush that the manufacturer stated should not be crushed (for example, long-acting or enteric coated medications) . 1. Resident #6 had diagnoses which included high blood pressure, edema, and atrial fibrillation. A 'Physician Order, dated 05/16/23, documented to administer Metoprolol Succinate extended release 12.5 mg by mouth every morning, Potassium Chloride extended release 20 milliequivalents by mouth every morning, and may crush meds and open capsules as appropriate. On 04/10/24 at 7:43 CMA #1 was observed to prepare…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview the facility failed to ensure staff maintained infection control measures, and a. changed gloves during provision of perineal care and personal hygiene for one (#55) of one sampled resident reviewed for perineal care, b. sanitized the blood pressure cuff and pulse oximeter during medication observation for three (#6, #64, and #23), and c. sanitized their hands between residents during medication observation for four (#17, #31, #144, #80) of eight sampled residents reviewed during medication pass observation. The Administrator identified 97 residents resided in the facility. Findings: A Cleaning and Disinfection or Resident-Care Items and Equipment policy revised October 2018, read in part, .Non-critical items are those that come in contact with intact skin but not mucous membranes .blood pressure cuffs .Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment . A Handwashing/Hand Hygiene policy, dated August 2019, read in parts, .Hand hygiene products and supplies…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure interventions were implemented for one (#14) of three residents sampled for falls. The DON identified 97 Residents resided in the facility. Findings: a. An Assessing Falls and Their Causes policy, revised 03/18, read in part, .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls . 1. Resident #14 had diagnoses which included macular degeneration, lesion of the plantar nerve, and osteoporosis. A Care plan document, dated 11/22/23, read in part, .Fall mats beside each side of her bed . Resident #14's comprehensive assessment, dated 03/25/24, documented Resident #14 was dependent for transferring from bed to chair and cognition was moderately impaired. On 04/09/24 at 9:36 a.m., Resident #14 was observed in bed unattended with bed in the lowered position. There were no fall mats observed on each side of the bed. On 04/09/24 at 9:41 a.m., CNA #1 was asked what interventions should have been in place to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to identify the time frames for the steps regarding the medication regimen review, and a medication regimen review was responded to timely for one (#45) of five sampled residents reviewed for unnecessary medications. The Administrator identified 97 residents resided in the facility. Findings: A Drug Regimen Review policy, revised March 2023, did not identify time frame for the steps regarding the medication regimen review. Resident #45 had diagnosis which included depression. An Order Summary report, dated 09/12/23, documented Resident #45 was to receive venlafaxine every morning for depression. A medication regimen review, dated 02/13/24, documented a request to the physician regarding a reduction of venlafaxine or provide a rationale why a dose reduction was clinically contraindicated. The response from the physician was dated 04/05/24. On 04/10/24 at 8:21 a.m., the DON stated staff reviewed the MRR with the physician then scanned in the requests in the residents' EHR. On 04/10/24 at 9:38 a.m., the DON stated there was not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure side effect monitoring was in place for a resident who was prescribed anticoagulant therapy for one (#3) of five residents sampled for unnecessary medication. The DON identified 29 residents were prescribed anticoagulants. Findings: A Anticoagulation-Clinical Protocol policy, revised 11/2018, read in part, .Assess for any signs or symptoms related to adverse drug reactions to to the medication alone or in combination with other medication .The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems . Resident #3 had diagnoses which included pulmonary embolism, hypertensive heart disease, and peripheral vascular disease. A Physician Order, dated 02/02/24, read in part, .Apixaban Oral Tablet 5 mg .Give 1 tablet by mouth two times a day . A Quarterly Assessment, dated 02/03/24 documented resident 3's cognition was intact and was prescribed anticoagulant therapy. Resident #3's care plan for anticoagulant therapy, dated 05/15/23, read 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-03 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to assess residents for the use of bed rails, educate residents and/or representatives on the risks and benefits of bed rails, and obtain an informed consent prior to the installation of bed rails for two (#15 and #16) of two sampled residents reviewed for bed rails. The Director of Nursing reported 62 residents with bed rails in place. Findings: A facility policy titled, Bed Safety and Mobility Devices, revision date December 2007, read in parts, .to try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: .Inspection by maintenance staff of all beds and related equipment as a part of our regular bed safety program to identify risks and problems including potential entrapment risks .identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment .The facility's education and training…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-03 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly 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 record review, observation, and interview, the facility failed to conduct regular inspections of beds, mattresses, and bed rails, as part of a regular maintenance program, for two (#15 and #16) of two residents reviewed for bed and bed rail inspections. The Resident Census and Conditions of Residents form documented 87 residents resided in the facility. Findings: A facility policy titled, Bed Safety and Mobility Devices, revision date December 2007, read in parts, .to try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: .Inspection by maintenance staff of all beds and related equipment as a part of our regular bed safety program to identify risks and problems including potential entrapment risks .identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment .The facility's education and training activities will include instruction about risk…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to have a medical justification for an indwelling urinary catheter (Foley catheter), and assess for removal of the catheter, for one (#10) of four residents reviewed for indwelling urinary catheters. The Resident Census and Conditions of Residents form documented seven residents with indwelling or external catheters. Findings: A policy, Appropriate Use of Indwelling Catheters, date implemented 03/03/23, documented in parts, .An indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary .each resident with urinary incontinence who is admitted with an indwelling urinary catheter will be assessed for removal of the catheter as soon as possible .The use of an indwelling catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary . Resident #10 was admitted on [DATE] with diagnoses which…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$6,338 in federal fines across 1 penalty.

  • $6,338 — penalty dated 2025-12-16

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

Who owns this facility

Owner / managerTypeRoleSince
FORREST, STACYIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 04/09/2022
JONES, ROBERTIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 06/19/2014
KRUGER, GEORGEIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/03/2015
SMITH, BRENTIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2014
FITCH, NATALIEIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/25/2021
HENRY, MARKIndividualCORPORATE DIRECTORsince 07/01/2021
LEGAKO, EDWARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/17/2016
MCCALL, CHARLESIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/13/2020
ZELBST, JOHNIndividualCORPORATE DIRECTORsince 07/01/1997
COMANCHE COUNTY HOSPITAL AUTHORITYOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/13/1971

CMS files one row per role, so the 19 rows in the source record cover these 10 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.

1 organizational owner 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.

$10.8M
Net patient revenuemost recent cost report
-12.4%
Operating marginrevenue minus expenses
$57K
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 25%Other / private 33%

This home reported $57K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$353per resident / day
operating cost
$10,727per month
≈ monthly operating cost
$314per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.

Typical monthly cost in Oklahoma
$7,026/mo
Nursing home (semi-private)
$7,756/mo
Nursing home (private)
$6,150/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375562. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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