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New Hope Retirement & Care Center

1220 East Electric Blvd, McAlester, OK 74501 · For profit - Individual · 55 certified beds · (918) 423-9095 Medicare & Medicaid certified

Call the home — (918) 423-9095 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Dec 2025Resident-funds citation (F0568)Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$7,371 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • 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 a citation for mishandling residents’ money or property (F0568)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $7,371 in federal fines (most recent 2024-07-31)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (73%) 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1401 E Van Buren Ave · (918) 423-3700 · Call to confirm hours
Pharmacy
2009 N Main St · (918) 302-9996 · Call to confirm hours
Grocery
2719 N Main St · (918) 426-4587 · Call to confirm hours
Park
801 N 9th St · (918) 421-4922 · Typically dawn to dusk
Place of worship
1655 Diesel Dr

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 3 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 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.

Overall rating1★
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 increased9.9%13.6%15.4%better
Long-stay residents who lose too much weight0.0%3.3%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder4.4%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection6.1%2.8%2.0%worse
Long-stay residents with depressive symptoms0.0%3.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury8.1%4.7%3.3%worse
Long-stay residents whose ability to walk worsened10.2%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.3%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine91.7%94.6%95.3%typical
Long-stay residents with pressure ulcers5.0%4.7%4.7%typical
Long-stay residents with worsening bladder/bowel control29.2%17.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.0%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Long-stay hospitalizations per 1,000 resident days2.252.311.67worse
Long-stay outpatient ER visits per 1,000 resident days3.612.961.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

54.8% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.8%U.S. median 51.5%
Got home and stayed home
12.6%U.S. median 10.7%
Went back to hospital
70.0%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 70.0% 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 20 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.8%CMS range 39.0–73.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.6%CMS range 8.2–18.010.7%Oct 2022–Sep 2024no 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 discharge70.0%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 discharge75.0%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 discharge65.0%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 identified29.4%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%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 worsened5.9%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 hospitalization8.2%CMS range 4.8–15.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.251.02Oct 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

0.36
RN hours/ resident / day
0.64
LPN hours/ resident / day
3.00
Aide hours/ resident / day
4.00
Total nurse hours/ resident / day
0.26
RN hoursweekends
73.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 55 beds and averages 37.4 residents a day — about 68% occupied, or roughly 18 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.00 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 3.63 hrs/resident/day on weekends vs 4.15 on weekdays — 12% thinner on weekends. RN hours go from 0.40 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 73% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2025-12-31)
8
at the previous standard inspection (2024-11-07)

Deficiencies are unchanged from the previous inspection. 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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2024-07-31 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide treatment and services to prevent worsening of a pressure ulcer for one (#4) of four sampled residents reviewed for pressure ulcers. The LPN #1 identified two residents with pressure ulcers. Findings: A facility pressure ulcer policy and procedure read in part, the facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility with pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable. The policy also read, aggressive and appropriate preventative measures and care are provided to address a resident's unique risk factors. Res #4 admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease, osteoporosis, and fracture of part of the neck of right femur. A care plan, dated 07/15/24, documented to assess skin condition and treat as needed. A nursing note, dated 07/15/24, documented a small pressure area…

    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 · E2025-12-31 · 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 — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a physician's order was followed for 1 (#42) of 1 sampled resident reviewed for respiratory care.The administrator identified one resident used a BIPAP machine.Findings: On 12/29/25 at 2:53 p.m., Res #42 was observed resting in bed, stated they were taking a nap. Res #42's BIPAP machine was not turned on, and the mask was sitting on the resident's bedside table. On 12/30/25 at 2:04 p.m., Res #42 was observed resting in bed with their eyes closed. Res #42's BIPAP machine was not turned on. The mask was observed sitting on the resident's bedside table.On 12/31/25 at 8:52 a.m., Res #42 was observed resting in bed with their eyes closed. Res #42's BIPAP machine was not turned on. The mask was observed sitting on the bedside resident's bedside table.A physician order, dated 07/14/25, showed BIPAP oxygen at 3 LPM at HS and while taking naps.On 12/31/25 at 2:21 p.m., RN #1 stated the resident should have had the BIPAP on during naps.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-31 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure dietary staff received training in safe food handling practices for the prevention of foodborne illness for 2 (Cook #3 and Dietary Aide #3) of 7 dietary staff reviewed for staff training. The administrator identified 37 residents received meals from the dietary department. Findings:On 12/22/25 at 11:10 a.m., the dietary manager was asked for verification of food handlers training for all dietary staff.On 12/30/25 at 3:00 p.m., the administrator submitted copies of food handlers training certificates for five of the seven dietary staff. The administrator stated cook #1 and dietary aide #3 had not received the required training.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-31 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to follow the menu for 1 of 1 meal services observed.The administrator identified 37 residents received nutrition from the kitchen.Findings:On 12/22/25 at 12:30 p.m., chicken fried steak, mashed potatoes and gravy, cream corn, dinner roll and pineapple crisp was observed to be served for the noon meal. The menu for week five showed crumb crusted chicken, savory rice, Brussel sprouts, dinner roll and pineapple crisp.An undated policy titled, Menu Substitution, read in part, menu substitutions will be recorded on a substitution record form. The reason for the change will also be noted. On 12/22/25 at 12:30 p.m., the dietary manager stated they were working off of the week five menu this week and had to substitute items due to not having the menu items available. The dietary manager stated they did not document substitutions or specific reasons for substitutions and did not have a form that they were aware of.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-31 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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. prepared food items were labelled with the preparation and use-by dates,b. food items were discarded after the expiration dates,c. temperature logs were accurate and completed for refrigerators and freezers,d. food temperatures were checked and logged for prepared food items, e. food was prepared in a sanitary environment, andf. food was not stored on the floor in dry storage area. The administrator identified 37 residents received nutrition from the kitchen. Findings:On 12/22/25 at 9:48 a.m., the following observations were made in the double door refrigerator in the kitchen:a. a container of prepared coleslaw with a manufacturer use by date of 12/13/25. b. a container of cottage cheese with a manufacturer use by date of 11/15/25. c. two plastic pitchers with lids with juice type liquid contents without label, preparation or use by datesOn 12/22/25 at 9:59 a.m., a log sheet titled Daily Refrigerator and Freezer Temperature Log, dated December 2025, was reviewed. There was no documentation 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-31 · 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

    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 time frame for 1 (#25) of 3 sampled residents reviewed for abuse. The administrator identified 37 residents resided in the facility. Findings:An undated facility policy titled Abuse Prohibition, read in part, the facility shall report all alleged violations and all substantial incidents to the state agency.An admission assessment, dated 12/21/24, showed Resident #25 had diagnoses which included unspecified dementia with behavioral disturbances, hyperlipidemia, anxiety disorder, and migraines.An allegation of abuse, reported to the facility administrator on 12/17/25, showed a facility staff member was observed to be rough while assisting Res #25 to a chair and spoke loudly to the resident. This allegation of abuse was not reported to the OSDH.On 12/31/25 at 12:10 p.m., the administrator stated the abuse allegation incident was reported to them and it was immediately investigated, including camera review by the cooperate office. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-31 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure assessments were accurate for anticoagulation therapy for 1 (#25) of 4 sampled residents reviewed for resident assessments.The administrator identified 37 residents resided in the facility. Findings:A quarterly assessment, dated11/05/25, showed Resident #25 received anticoagulant therapy.Resident #25's medication administration record, dated November 2025, did not show an anticoagulant medication.On 12/31/25 at 12:42 p.m., the minimum data set coordinator stated Resident #25 did not take an anticoagulant medication. They stated the assessment was coded in error and would be modified.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure the removal of expired medications and supplies from 1 of 1 medication rooms observed.The administrator reported 37 residents resided in the facility.Findings: On 12/31/25 at 1:15 p.m., the medication storage room was observed with RN #1. The following medications/supplies were observed to be expired:One box of 25-gauge needles with 3 ml syringe with an expiration date of 08/31/25,One box of 21-gauge needles with 3 ml syringe with an expiration date of 12/02/25,Four packets of Dyna Lube (a lubricating jelly) with an expiration date of 03/20/20,Eight tubes of lubricating jelly with an expiration date of 11/24/22,Eleven bisacodyl suppositories with an expiration date of 08/05/25,Six bisacodyl suppositories with an expiration date of 03/24/25.On 12/31/25 at 1:30 p.m., RN #1 stated the expired medications and supplies should have already been removed.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0880 — failed to prevent and control infections — isolated
    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 to ensure the water management plan to prevent waterborne pathogens had the participation of the infection preventionist. The administrator identified 37 residents resided in the facility.Findings:A facility policy titled Legionella Water Management Program, dated 1/2022, read in part, As part of the infection prevention control program, our facility has a water management program, which is overseen by the water management team. The document also showed:a. there was a water management team consisting of the infection preventionist, the administrator, the medical director or their designee, the director of maintenance, and the director of environmental services,b. a detailed description and diagram of the water system in the facility, including receiving, cold water distribution, heating, hot water distribution and waste, andc. the identification of areas in the water system that could encourage growth and spread waterborne bacteria.A facility cleaning schedule attached to the Legionella water management program for 2025,…

    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 before2025-07-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 physical environment was maintained in good repair.The administrator identified 39 residents resided in the facility.Findings:On 07/15/25 at 7:55 a.m., during a tour of the dining room, the ceiling was observed to have multiple ceiling tiles with large brown watermark stains.On 07/17/25 at 3:30 p.m., during a tour of the facility, resident rooms #2, #4, #17, and #28 were observed to have sagging white ceiling tiles. The ceiling tiles had brown watermark stains around and near the air vents.A policy titled Homelike Environment, revised February 2021, read in part, Residents are provided with a safe, clean, comfortable and homelike environment.On 07/17/25 at 3:42 p.m., the maintenance supervisor stated the sagging tiles with brown watermark stains were caused by water leaks from the roof. They stated the facility's roof leaked every time it rained. The maintenance supervisor stated they tried to change out the stained and sagging ceiling tiles often, but the roof needed to be permanently repaired.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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-16 · tag F0656 — failed to write and follow a full care plan — isolated
    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 — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for indwelling urinary catheter care and maintenance for 1 (#2) of 2 residents sampled for indwelling urinary catheters.The administrator identified one resident with an indwelling urinary catheter.Findings:An undated medical diagnosis list showed Res #2 had diagnoses which included retention of urine and congenital bladder neck obstruction.A physician order, dated 08/07/24, showed to change the indwelling urinary catheter every 30 days and as needed and to perform catheter care every shift and as needed.A quarterly assessment, dated 08/21/24, showed Res #2 had a BIMS score of 12 and was cognitively intact. The assessment showed Res #2 had an indwelling urinary catheter.Res #2's care plan was reviewed. There was no documentation for indwelling urinary catheter care and maintenance shown on the care plan.On 07/15/25 at 4:35 p.m., the MDS coordinator stated a comprehensive care plan for urinary catheter care and maintenance had not been developed for Res #2, but should have been.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2025-07-16 · tag F0657 — failed to keep the care plan current — isolated
    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

    Based on record review and interview, the facility failed to update a resident's care plan after abusive behavior was observed for 1 (#3) of 3 sampled residents reviewed for abuse.The administrator identified 39 residents resided in the facility.A care plan policy, revised March 2022, showed care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The policy showed when possible, interventions addressed the underlying sources of the problem areas, not just symptoms or triggers. The policy showed assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions change.A facility reported incident, dated 04/27/25, showed an allegation of abuse/mistreatment involving Resident #3 and Resident #6. The reported incident showed resident to resident abuse by staff. Immediate separation of residents. Alleged abuser had one on one provided while arrangements…

    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 · D2025-07-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the physician of signs and/or symptoms of a potential infection at a urinary catheter's entry site for 1 (#2) of 2 residents sampled for indwelling urinary catheters.The administrator identified one resident with an indwelling urinary catheter.Findings:An undated policy titled Communication of Resident Condition and Treatment with Antimicrobial Orders, read in part, When facility staff suspects a resident has an infection, the nurse should appropriately document a comprehensive assessment of the resident using established and accepted assessment protocols. This assessment will determine if the resident's status meets minimum criteria for initiating antibiotics. When contacting a physician to communicate to discuss a resident's change in condition and a suspected infection, a nurse should have the medical record available and should communicate the following: written results of the written resident assessment, signs and symptoms, and time…

    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 · F2024-11-07 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to post the required staffing information. The administrator identified 39 residents who resided in the facility. Findings: On 11/05/24 at 11:00 a.m., posted staffing was observed to be documented on a white board at the nursing station. The date, census, and staff/title were documented. The facility name and projected and actual staffing hours were not documented. On 11/07/24 at 9:02 a.m., posted staffing was observed to be documented on a white board at the nursing station. The date, census, and staff/tile were documented. The facility name and projected and actual staffing hours were not documented. On 11/07/24 at 9:52 a.m., the DON reported they were unaware of what staffing information was required to be documented on the staffing board.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to date and cover urinary catheter bags for two (#11 and #35) of two sampled residents reviewed for urinary catheters. The DON identified four residents with urinary catheters. Findings: 1. Res #11 had diagnoses which included overactive bladder, paraplegia, and a stage 4 sacral pressure ulcer. A physician order, dated 05/29/23, documented catheter care per facility guidelines. A discharge return anticipated assessment, dated 10/24/24, documented the resident was modified independent for daily decision making and had a urinary catheter. On 11/05/24 at 11:00 a.m., the resident was lying in bed with a urinary catheter bag hanging from the bedside. The bag was not dated or covered. On 11/07/24 at 2:23 p.m., the DON stated the resident's urinary catheter bag should have been dated and covered. 2. Res #35 had diagnoses which included retention of urine and congenital bladder neck obstruction. A physician order, dated 08/07/24, documented catheter care per facility guidelines. On 11/05/24 at 11:21 a.m., the resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor 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 DNR orders were in place for three (#4, 7 and #10) of 14 sampled residents whose advance directives were reviewed. The administrator identified 12 residents who were DNR's. Findings: A Do Not Resuscitate Order policy, dated [DATE], read in part, 1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. 1. Res #4 had diagnoses which included type 2 diabetes mellitus and cerebral infarction. A Do Not Resuscitate care plan, dated [DATE], documented Res #4 did not want CPR performed if their heart/respirations should stop. Res #4 signed an Oklahoma Do Not Resuscitate (DNR) Consent Form was signed on [DATE]. Res #4 did not have a physician's order for a DNR. 2. Res #7 had diagnoses which included Parkinson's, dementia, behavioral disturbance, and anxiety. A Do Not Resuscitate care plan, dated [DATE], documented Res #7 did not want CPR performed if…

    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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 out of parameter blood sugars for two (#21 and #31) of three sampled residents whose diabetic records were reviewed. The administrator identified 12 residents whose blood sugars were monitored. Findings: 1. Res #21 had diagnoses which included type 2 diabetes with autonomic polyneuropathy. A physician's order, dated 04/26/24, read in part, Obtain and record FSBS (finger stick blood sugar) .ac and hs. Notify physician if FSBS <70 or >400. On 10/02/24 at 4:30 p.m., Res #21's blood sugar was 458. There was no documentation in the narrative note or blood glucose MAR the physician was notified of the out of parameter blood sugar. 2. Res #31 had diagnoses which included type 2 diabetes mellitus. A physician's order, dated 08/12/23, read in part, Obtain and record FSBS .ac and hs .Notify physician if FSBS <60 or >400. There was no documentation in the narrative note or blood glucose MAR the physician was notified of the following out of parameter blood sugars: a. on 09/20/24 at 10:10 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0641 — isolated
    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 resident assessments were accurate for two (#21 and #28) of 14 sampled residents whose resident assessments were reviewed. The administrator identified 39 residents who resided in the facility. 1. Res #21 had diagnoses which included heart failure, cerebral infarction, and history of pulmonary embolism. A physician's order, dated 09/24/22, documented the resident was taking aspirin (antiplatelet mecication) 81 mg daily. A 5 day resident assessment, dated 09/24/24, documented the resident was taking an anticoagulant. The resident assessment did not document the resident was taking an antiplatelet. On 11/07/24 at 10:55 a.m., the MDS coordinator reported the medication section of the resident assessment is auto-populated and they did not catch the error of an anticoagulant being documented. The MDS coordinator reported antiplatelet should have been documented. 2. Res #28 had diagnoses which included atrial fibrillation and chronic obstructive pulmonary disease. A physician's order, dated 08/21/24, documented 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 · D2024-11-07 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management 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 resident experiencing pain was monitored for pain for one (#39) of one sampled resident reviewed for pain. The administrator identified 39 residents who resided in the facility. Findings: Res #39 had diagnoses which included muscle spasm, pain, and anxiety disorders. A physician order, dated 09/27/24, documented the resident was to receive Tramadol (a narcotic medication) 50 mg two tablets by mouth every eight hours as needed for pain. The resident did not have a physician order for scheduled pain medication. An admission assessment, dated 10/01/24, documented the resident was cognitively intact and had occasional pain rated six on a pain scale from 0 to 10. The care plan, dated 10/04/24, documented the resident had pain. The care plan documented the resident was to have pain relieved or controlled as evident by facial expression and verbalization of pain relief. A physician order, dated 10/15/24, documented staff was to monitor the resident's pain daily every morning, evening, and night shift. The staff was 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 · D2024-11-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 a resident who received psychotropic medication had an acceptable diagnosis/indication for the use of an antipsychotic medication for one (#33) of five sampled residents reviewed for unnecessary medications. The DON identified 10 residents who received antipsychotic medications. Findings: Res #33 had diagnoses which included dementia without behavioral or psychotic disturbances, anxiety disorders, and unspecified mood affective disorder. A physician order, dated 10/21/24, documented the resident was to receive Risperidone (an antipsychotic medication) 0.5 mg two times a day. The admission assessment, dated 10/28/24, documented the resident was cognitively intact and was receiving a antipsychotic and a antianxiety medication. The care plan, dated 11/01/24, documented the resident received psychotropic medication. The care plan documented staff were to monitor for behaviors, verbal and non-verbal, for which the medication was being given. On 11/06/24 at 4:01 p.m., the DON reviewed the resident's clinical record. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure there was documentation of the coordination of care between hospice and the facility for one (#28) of one sampled resident reviewed for hospice care. The DON identified three residents who received hospice services. Findings: Res #28 had diagnoses which included atrial fibrillation and chronic obstructive pulmonary disease. A physician's order, dated 08/21/24, documented the resident was admitted to hospice services for a diagnosis of chronic obstructive pulmonary disease. The admission assessment, dated 08/27/24, did not document the resident was receiving hospice services. On 11/06/24 at 2:41 p.m., the administrator could not provide hospice documentation regarding the resident's hospice services, including the plan of care.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-17 · tag F0655 — isolated
    Create 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 a baseline care plan was accurate for one (#1) of three sampled residents whose care plans were reviewed. The administrator identified a census of 46 residents. Findings: Res #1 was admitted on [DATE] with diagnoses which included right hip fracture, osteoarthritis, hypertension, anxiety and impulse disorder. Res #1's progress notes documented the resident was in the hospital with an infected right hip incision and returned to the facility on [DATE] with a JP Drain, indwelling urinary catheter, wound vac to right hip incision, PICC line with IV antibiotics and wounds to coccyx and buttocks. Res #1's baseline care plan started on 05/09/24 and updated on 05/21/24 did not include a care plan for Res #1's JP drain, indwelling urinary catheter, wound vac to right hip incision, PICC line with IV antibiotics and wounds to coccyx and buttocks. On 06/17/24, the DON reported the baseline care plan for Res #1 should have included a plan for Res #1's JP…

    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 · Dcited before2024-01-24 · 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 all allegations of abuse were reported within two hours for one (Res #1) of three residents sampled for abuse. The facility identified two incidents of abuse which occurred in the previous five months. Findings: A facility policy, titled Abuse Prohibition 12/19/16, read in part, .If you have any concerns regarding these issues, you have a duty to contact us immediately through one or more of the following resources: * The Administrator/Designee *DON *ADON *Charge nurse .3 .shall as soon as possible report information supporting the belief to the Department of Health, APS, local law enforcement and ombudsman, by telephone, in writing or by personal visit .When in doubt as to the reportability of an event, report it . A nurse note documented in Res #1's general notes, dated 11/26/23 at 2:10 p.m., documented a hospital had called report to the charge nurse in preparation to send Res #1 back to the facility. The note documented the hospital told 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-24 · 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 all allegations of abuse were thoroughly investigated for one (Res #1) of three residents sampled for abuse. The facility identified two incidents of abuse which occurred in the previous five months. Findings: A facility policy, titled Abuse Prohibition 12/19/16, read in part, .Investigations: The facility shall ensure, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment . A nurse note documented in Res #1's general notes, dated 11/26/23 at 2:10 p.m., documented a hospital had called report in preparation to send Res #1 back to the facility. The note documented the hospital told the nurse at the facility Res #1 had stated they were being sexually abused, abused, and poisoned at the facility. On 01/24/24 at 4:16 p.m., the administrator was asked if the facility had investigated the allegation of abuse, documented as being reported to the facility on [DATE]. The administrator stated the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-18 · tag F0568 — pattern
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to provide trust account residents with a quarterly account statement. The VP of Operations identified 16 residents who were in the trust account. Findings: The undated Protection Of Resident Funds policy, read in part, .Shall provide each resident or his/her representative with a written itemized statement at least quarterly of all financial transactions involving the resident's funds . A review of the trust account records did not include a quarterly statement for April - June 2023. On 08/17/23 at 3:20 p.m., the VP of Operations reported they took over the residents' trust accounts in April 2023, but didn't provide the residents with account statements until 08/01/23.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 ensure hot water was available in resident rooms for 17 of 19 resident rooms reviewed for hot water. Findings: A floor plan of the facility with no date, documented 19 rooms were occupied by residents. On 08/14/23 at 9:45 a.m., the hot water in the sink of room [ROOM NUMBER] was allowed to run for three minutes and showed a temperature of 75 degrees Fahrenheit On 08/14/23 at 9:50 a.m., Res #31 reported the hot water in the sink did not work and hadn't for a long time. On 08/15/23 at 9:30 a.m., the hot water in the sinks of rooms [ROOM NUMBERS] was allowed to run for three minutes and showed a temperature of 76 degrees Fahrenheit. On 08/15/23 at 9:40 a.m., Res #9 reported there had been no hot water from the sink for a few months in room [ROOM NUMBER]. On 08/15/23 at 9:45 a.m., CNA #1 reported sometimes it took a long time for the water to get hot in the resident rooms. On 08/15/23 at 3:00 p.m. the administrator reported prior to the surveyor asking about…

    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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-18 · 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 ensure the physician responded to monthly pharmacist consultations for two (#9 and #31) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents, dated 08/14/23, documented 31 residents received psychoactive medications. Findings: 1. Res #9 was admitted with diagnoses which included bipolar, schizophrenia, and Alzheimer's. A physician's order, dated 11/16/21, documented to administer Seroquel (an antipsychotic medication) 75 mg twice daily. A physician's order, dated 02/14/22, documented administer Depakote (a mood stabilizing medication) 250 mg twice daily. A Pharmacist Review, dated 05/09/23 documented in part, Is a dosage reduction attempt possible for any of the following: Zoloft from 50 mg daily, Seroquel from 75 mg twice daily, Depakote 250 mg twice daily as this is used for bipolar disorder? A Pharmacist Review, dated 05/09/23, documented in part, .Decrease Zoloft to 25. There was no documentation regarding the recommendation to reduce the dosage of the Depakote or…

    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

“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

$7,371 in federal fines across 1 penalty.

  • $7,371 — penalty dated 2024-07-31

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
ASPIRE MANAGEMENT LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/11/2016
MONTGOMERY, THOMASIndividualDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/11/2016
LOWE, TINAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/11/2016
BULLY GOOD INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/11/2016
ANDERSON, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
COOLEY, CHELSEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2021
MANAGEMENT SERVICES INCOrganizationADP OF THE SNFsince 10/01/2016

CMS files one row per role, so the 17 rows in the source record cover these 7 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.

3 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.

$2.6M
Net patient revenuemost recent cost report
-16.0%
Operating marginrevenue minus expenses
$180K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 6%Other / private 9%

About 84% 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 $180K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$293per resident / day
operating cost
$8,893per month
≈ monthly operating cost
$252per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

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 375384. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, 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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