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Sienna Extended Care & Rehab

9221 Harmony Drive, Midwest City, OK 73130 · For profit - Corporation · 100 certified beds · (405) 869-0700 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Apr 2025Resident-funds citations (F0568, F0570)1 immediate-jeopardy citation
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Apr 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has citations for mishandling residents’ money or property (F0568, F0570)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
9060 Harmony Dr · (405) 759-2562 · Call to confirm hours
Pharmacy
1212 S Douglas Blvd · (405) 741-1200 · Call to confirm hours
Grocery
1064 S Douglas Blvd · (405) 737-1320 · Call to confirm hours
Park
9555 SE 15th St · (405) 593-0333 · 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 3 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 held steady at 1 stars. From monthly CMS archive snapshots.

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

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 increased10.2%13.6%15.4%better
Long-stay residents who lose too much weight5.0%3.3%5.4%typical
Long-stay residents with a catheter left in their bladder1.9%1.9%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.9%2.8%2.0%better
Long-stay residents with depressive symptoms0.5%3.4%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.4%4.7%3.3%worse
Long-stay residents whose ability to walk worsened2.7%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.7%25.7%18.9%typical
Long-stay residents given the seasonal flu vaccine69.7%94.6%95.3%worse
Long-stay residents with pressure ulcers10.7%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control21.9%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table10.7%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication2.7%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine81.9%74.1%79.4%typical
Short-stay residents rehospitalized after admission21.6%27.3%22.6%typical
Short-stay residents with an outpatient ER visit19.8%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.602.311.67worse
Long-stay outpatient ER visits per 1,000 resident days2.352.961.80worse

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.

49.3% 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 223 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.3%U.S. median 51.5%
Got home and stayed home
13.2%U.S. median 10.7%
Went back to hospital
55.4%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 55.4% 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 65 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 SNF49.3%CMS range 43.5–56.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.2%CMS range 9.9–16.710.7%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 discharge55.4%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 discharge60.0%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 discharge64.6%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 identified78.4%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 setting97.4%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 discharge95.9%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 stay1.8%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 worsened3.6%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 hospitalization9.0%CMS range 6.0–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 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

0.11
RN hours/ resident / day
0.92
LPN hours/ resident / day
2.33
Aide hours/ resident / day
3.36
Total nurse hours/ resident / day
0.12
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 100 beds and averages 82.3 residents a day — about 82% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.11 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.95 hrs/resident/day on weekends vs 3.53 on weekdays — 16% thinner on weekends. RN hours go from 0.11 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

12
deficiencies at the latest standard inspection (2025-04-21)
4
at the previous standard inspection (2023-12-21)

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

Inspection deficiencies

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

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.

31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · K2023-01-10 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 01/06/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure policy was followed regarding allegations of misappropriation of pain medication signed out and not documented as given. On 01/03/23, LPN #1 signed out four narcotic pills for Resident #36, these were not documented as administered on the MAR. Upon interview, Resident #36 stated they did not receive any pain medications on 01/03/23. On 01/04/23, LPN #1 was observed signing out two doses of a narcotic pain medication when the count sheet for Resident #36 count was determined to be inaccurate during shift change. Resident #36 was not in the building at this time. LPN #1 returned to work on 01/04/23 despite the policy stating the employee would be suspended pending an investigation. LPN #1 signed out narcotics for Resident #54 fourteen times from 10/13/22 through 01/03/23 that were not documented as administered to the resident on the MAR. The potential for residents to go with untreated pain is…

    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 · G2023-01-10 · 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 record review, observation and interview, the facility failed to ensure: a. Thorough skin assessment was conducted on readmission, b. Weekly skin monitoring and/or weekly wound assessments were conducted, c. The physician was notified timely of the new or worsening wound; and d. Adequate wound care/treatment was initiated timely for one (#11) of three sampled residents reviewed for pressure ulcers. This resulted in actual harm to Resident #11 who developed a pressure injury which worsened to an avoidable pressure injury with slough visible. The DON identified 71 residents who were at risk for skin breakdown. Findings: The facility's Wound Care policy, revised October 2010, read in parts, The purpose .is to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order .Review the resident's care plan to assess for any special needs of the resident .The following information should be recorded in the resident's medical record .The type of wound care given .any changes in the resident's condition All assessment data .Report other…

    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 · F2025-04-21 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to post the most recent state survey results of the facility in a place readily accessible to residents, family members, and legal representatives of the residents. The administrator identified 68 residents resided in the facility. Findings: On 04/17/25 at 9:17 a.m., a framed form that showed Copies of all [NAME] surveys and results are available to view on the table at the north end of our main entrance was observed on the wall directly outside of the dining room. On 04/17/25 at 9:21 a.m., the surveyor walked to the front entrance and did not observe the survey results on any table at the north end of the main entrance. A Survey Results policy, revised 04/2007, read in part, A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports .along with the state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents,…

    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 · E2025-04-21 · tag F0570 — pattern
    Assure the security of all personal funds of residents deposited with the facility.
    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 total amount of resident funds in the facility trust account did not exceed the amount covered under the facility surety bond. The DON identified 11 residents in the facility trust account resided in the facility. Findings: An undated facility form titled, Personal Funds Authorization, read in part, The facility maintains one trust fund account for both private and Medicare resident/patients .The facility has purchased a surety bond, or otherwise provided assurance satisfactory to the Secretary of the Department of Health and Human Services, to assure the security of all personal deposited with the facility. The facility trust account showed the following balances: a. statement date 06/30/24 beginning balance $39,450.07 ending balance $40,587.06; b. statement date 08/31/24 beginning balance $32,086.12; c. statement date 02/28/25 ending balance $28,346.24; and d. statement date 03/31/25 beginning balance $28,346.24. The facility surety bond, current bond term 08/20/22 through 08/20/25, showed the bond amount was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-21 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 residents had the right to voice grievances to the facility without fear of discrimination or reprisal and failed to promptly resolve grievances the residents had in the resident council group. The administrator identified 68 residents resided in the facility. Findings: An undated facility form, Resident's/Patient's Rights, read in part, You have the right to voice problems that you are concerned about regarding your treatment .Anyone who denies any of these rights is punishable by fine and/or imprisonment .If you are denied your rights, you may also be allowed punitive damages .There can be no retaliation of any type by the facility staff because of a complaint presented to the staff. The resident council minutes, dated 01/27/25, showed old business: still out of dietary items and everything they ordered or requested was usually out. The resident council minutes showed to see the 01/29/25 meeting for how the issue was resolved. The minutes showed new business: dietary rush when asking for orders and are always out…

    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 · Ecited before2025-04-21 · 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 resident assessments were coded for 2 (#1 and #48) of 19 sampled residents reviewed for accuracy of resident assessments. The administrator identified 68 residents resided in the facility. Findings: 1. A hospice services contract, dated 11/08/24, showed Resident #1 had started hospice services on that date. A significant change MDS assessment, dated 11/19/24, was completed due to Resident #1 beginning hospice services. The assessment showed Resident #1 had a diagnosis of heart disease and a BIMS score of 12, indicating they were moderately cognitively impaired. A care plan, dated 01/20/25, showed Resident #1 had a terminal diagnosis and was receiving hospice services. A quarterly MDS assessment, dated 02/19/25, showed that Resident #1 was not on hospice services. On 04/17/25 at 11:05 a.m., the MDS coordinator stated the quarterly assessment was coded incorrectly and should have shown that Resident #1 was receiving hospice services. On 04/17/25 at 11:08 a.m., the DON stated the MDS assessments are supposed to be…

    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 before2025-04-21 · 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: a. follow EBP during the provision of care for 1 (#14) of 3 sampled residents reviewed for activities of daily living; and b. transport dirty linen appropriately and sanitize their hands between meal set up for different residents on hall 200. The administrator identified 68 residents resided in the facility. The DON identified 18 residents were on EBP. Findings: 1. On 04/15/25 at 12:42 p.m., CNA #4 entered Resident #14's room to answer their call light. The resident's representative informed CNA #4 the resident was wet. On 04/15/25 at 12:43 p.m., CNA #4 donned gloves. There was an EBP sign on the resident's closet. Gowns were observed on top of the resident's closet. There was an EBP sign, gloves, and hand sanitizer by the resident's room entrance. Resident #14 ambulated to the bathroom with CNA #4's supervision. There was a yellow ring on the center of the resident's sheet. On 04/15/25 at 12:50 p.m., CNA #4 assisted the resident with toileting and changed their clothing. CNA #4 did not have a gown on. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · 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 record review and interview, the facility failed to ensure residents were free from misappropriation for 1 (#177) of 3 sampled residents reviewed for abuse. The administrator identified 68 residents resided in the facility. Findings: The facility abuse, neglect, exploitation and misappropriation prevention program, revised 04/2021, read in part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. A new employee form showed CNA #2 had a hire date of 12/06/24. A quarterly resident assessment, dated 02/24/25, showed Resident #177 had severe cognitive impairment (BIMS 07). An email correspondence to the administrator, dated 03/17/25, showed the family of Resident #177 discovered six unauthorized charges to the resident's debit card during their stay at the facility. The email correspondence showed there were four withdrawals made and deposited to a cash app account on 01/01/25 for a total 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · 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: a. an abuse allegation was reported to APS for 2 (#8 and #21); and b. an initial abuse allegation was reported to the state agency within two hours for 1 (#21) of 3 sampled residents reviewed for abuse. The administrator identified 68 residents resided in the facility. Findings: An Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised 09/2022, read in part, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies .The stated licensing/certification agency responsible for surveying/licensing the facility .Adult protective services .Immediately .within two hours of an allegation involving abuse. 1. A quarterly resident assessment, dated 02/13/25, showed Resident #21'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-21 · 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

    Based on observation, record review, and interview, the facility failed to complete skin assessments as ordered for 3 (#1, 12, and #24) of 5 sampled residents reviewed for non-pressure skin conditions. The administrator identified 68 residents resided in the facility. Findings: 1. Resident #1's order summary report, dated 04/2025, had diagnoses which included peripheral autonomic neuropathy, protein-calorie malnutrition, and need for assistance with personal care. Resident #1's quarterly resident assessment, dated 02/19/25, showed the resident had moderate cognitive impairment with a BIMS of 12. A physician's order, dated 11/04/24, showed weekly skin assessments on Tuesdays from 7 a.m. to 3 p.m. Skin only evaluation (in assessments) was to be filled out. Document all findings. Obtain treatment order if needed one time a day every Wednesday. The last skin assessment for Resident #1 was dated 08/07/24. On 04/21/25 at 9:18 a.m., LPN #1 stated the last skin only evaluation they see in Resident #1's medical records was dated 08/07/24. 2. On 04/16/25 at 8:28 a.m., Resident #12 had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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

    Based on observation, record review, and interview, the facility failed to administer a resident's oxygen as ordered for 1 (#12) of 3 sampled residents reviewed for respiratory care. The DON identified seven residents received continuous oxygen in the facility. Findings: On 04/16/25 at 8:24 a.m., Resident #12's oxygen concentrator was observed to be at a flow rate of 2 liters per minute via a nasal cannula. On 04/17/25 at 11:16 a.m., LPN #2 made observation of the oxygen flow rate on resident #12's concentrator. A policy titled Oxygen Administration, dated 2001, read in part, The purpose of this procedure is to provide guidelines for safe oxygen administration .Review the physician's orders or facility protocol for oxygen administration. Resident #12's order summary report, dated 04/2025, showed the resident had a diagnosis of chronic obstructive pulmonary disease. A physician's order, dated 02/05/24, showed oxygen via nasal cannula at 5 liters continuously. May titrate to keep saturation above 90%. On 04/17/25 at 11:20 a.m., LPN #2 stated the resident's concentrator was set 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 · Dcited before2025-04-21 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents' medications were only accessible to qualified staff. The administrator identified 68 residents resided in the facility. The administrator identified the facility had three medication rooms. Findings: On 04/16/25 at 10:55 a.m., life safety was on tour with the maintenance supervisor. The maintenance supervisor used their key to open the medication storage room by the DONs office. No other staff were present at the time. The maintenance supervisor walked over to the medication room on hall 500 and opened the door using their key. No other staff were present at the time. On 04/16/25 at 12:17 p.m., LPN #1 opened the medication storage room by the DONs office. There were numerous containers of residents' medications observed in the room. On 04/16/25 at 12:35 p.m., ACMA #1 opened the medication storage room on hall 500. There were numerous containers of residents' medications observed in the room. On 04/16/25 at 2:45 p.m., the maintenance supervisor had the medication room door by the DONs office…

    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
Show the remaining 19 citations
  • Potential for harm · D2025-04-21 · tag F0801 — isolated
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure the dietary manager completed certification as a certified dietary manager within three years of beginning employment per state requirement. The administrator identified 68 residents resided in the facility and 66 residents ate from the cafeteria. Findings: The DM was hired on 11/22/2011. There was no documentation the DM had completed certification as a certified dietary manager. On 04/16/25 at 1:23 p.m., the dietary manager stated they had worked in the role of dietary manager since 2011 and had not been certified. They stated they started the classes, but never completed them. They also denied having the other qualifiers accepted by the regulations to be considered certified. On 04/21/25 at 10:04 a.m., the administrator stated the DM was supposed to get certified within 3 years. The administrator stated, I was told they did the class.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0943 — isolated
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined the facility failed to ensure dementia management education was provided to 1 (LPN #2) of 1 staff member who cared for residents with dementia. The administrator identified 18 residents had diagnosis of dementia in the facility. Findings: 1. Resident #3 had diagnoses which included vascular dementia. An annual resident assessment, dated 02/07/25, showed the resident's cognition was severely impaired (BIMS 00). Resident #3's care plan, dated 03/08/24, showed the resident had behavioral issues related to yelling out, throwing food, and was combative at times. 2. Resident #15's care plan, dated 03/24/25, showed the resident had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. It showed the resident had impaired cognitive function or impaired thought processes related to dementia. Resident #15's quarterly resident assessment, dated 03/28/25, showed the resident's cognition was severely impaired with a BIMS of 03. It showed 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 before2024-02-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure medications were administered as ordered for one (#1) of one sampled residents reviewed for intravenous medications as order by the physician. Social Services identified 73 residents resided in the facility. Findings: Resident #1 had diagnoses which included sepsis, unspecified organism and cellulitis of left upper arm. A physician's order, dated 09/19/23 documented ceftriaxone sodium injection solution, reconstituted 2 GM (Ceftriaxone sodium) use 2 gram intravenously one time a day for eight days with a start date of 09/20/23. A physician's order, dated 09/20/23 documented flush NS 10 ml per lumen every shift. The September MAR documented blanks on 09/25 and 09/26/23 for the ceftriaxone sodium and the flush documented four blanks out of 21 opportunities. On 02/08/24 at 11:38 a.m., the DON stated I can not verify by the MAR that she received the anitbiotic or flushes or not. On 02/08/24 at 12:03 p.m., LPN #1 stated if there are blanks on the MAR it is assumed it wasn't given, andif there is no…

    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 before2023-12-21 · 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 resident assessments were accurately coded for three (#27, 45, and # 52) of 18 sampled residents reviewed for resident assessments. The Administrator identified 70 residents resided in the facility. Findings: 1. Resident #52 had diagnoses which included chronic kidney disease stage four and vascular dementia. An admission Resident Assessment, dated 09/22/23, documented the resident received a diuretic seven days of the seven day look-back period. There was no documentation Resident #52 had received a diuretic medication. On 12/19/23 at 2:56 p.m., MDS Coordinator #1 stated they reviewed resident charts, talked to staff and residents, and reviewed orders and documents to ensure resident assessments were accurately coded. The stated Resident #52's admission Resident Assessment documented they received a diuretic and an antidepressant. MDS Coordinator #1 reviewed the resident's record and stated the resident had not received a diuretic medication. 2. Resident #27 had diagnoses which included dementia and palliative…

    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 before2023-12-21 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure: a. medications for administration were not left at the resident's bedside for one (#55) of 24 residents observed during initial pool; and b. medications were administered as ordered for two (#27 and #54) of five sampled residents reviewed for unnecessary medications. The administrator identified 70 residents resided in the facility and no residents with orders to self administer medications. Findings: An Administering Medications policy, revised 04/19, read in part, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders .Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined they have the decision making capability to do so safely . 1. Resident #55 had diagnoses which included schizophrenia, dementia, insomnia, and chronic pain syndrome. On 12/18/23 at 9:16 a.m., Resident #55 stated it took the facility six…

    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 · E2023-12-21 · 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 food items were dated and labeled appropriately for one of one kitchen observation. The Dietary Manager identified 69 residents who received meals from the kitchen. Findings: A Food Receiving and Storage policy, revised 11/22, read in part, .all foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) .other opened containers are dated and sealed or covered during storage . On 12/18/23 at 8:35 a.m., cherry fountain syrup was observed in the dry storage room with no open date with one third of it used. On 12/18/23 at 8:44 a.m., tartar sauce was observed in the refrigerator with no open date and two thirds used. Chocolate cupcakes were observed in the refrigerator with no label or date. On 12/18/23 at 8:46 a.m., garlic spread was observed in the refrigerator with no open date and half used. On 12/18/23 at 9:13 a.m., the Dietary Manager stated they could not identify when the tartar sauce or garlic sauce was opened. They stated there would be no way to identify when 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure staff donned personal protective equipment in transmission based precautions room for one (#77) of eight residents observed receiving their meal trays. The Daily Census, dated 12/17/23, identified two residents on isolation precautions for COVID-19. Findings: A Personal Protective Equipment policy, revised 10/18, read in part, .personnel who perform tasks that may involve exposure to blood/body fluids .employees who fail to use personal protective equipment when indicated may be disciplined . A Respiratory Surveillance Line List documented Resident #77 had tested positive for COVID-19 on 12/12/23. On 12/18/23 at 12:34 p.m., CNA #1 was observed passing a tray to Resident #77 on hall 400. The CNA did not use any personal protective equipment to enter the room and set up the tray for Resident #77. There was a PPE sign and equipment observed right outside of the resident's room. On 12/18/23 at 12:36 p.m., CNA #1 stated they forgot the resident had a sign on the door and paid no attention honestly.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-13 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure trust account statements were provided quarterly to three ( #2, 5 and #7) of three sampled residents reviewed for trust accounts. The Administrator identified 15 residents in the resident trust account. Findings: An Accounting and Records of Resident Funds policy, revised 04/21, read in parts .Our facility maintains accounting records of resident funds deposit with the facility .Individual accounting records are made available to the resident through quarterly statements and upon request . The form identified Resident #3, #5 and #7 had trust accounts. 1. Res. #2 had diagnosis which included atrial fibrillation, fluid overload, depression, morbid obesity, and cognitive communication deficit. On 10/11/23 at 10:04 a.m., Resident #7 was asked if they received quarterly statements for the trust account. They stated they were unsure, they would like to see them. 2. Res. #5 had diagnosis which included acute respiratory failure, seizures, diabetes mellitus, anxiety, dementia. 3. Res. #7 had diagnosis which included…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-13 · 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: a. assess bowel sounds post-abdominal surgery for one (#3), b. obtain fingerstick blood sugars as ordered for two (#3 and #4), and c. monitor vital signs every shift as ordered for one (#3) of three sampled residents reviewed for physician orders. The DON identified 21 residents were insulin dependent and 81 residents resided in the facility. Findings: A Diabetes-Clinical Protocol policy, revised 11/20, read in part .As indicated, the Physician will order appropriate lab tests .monitor 3 to 4 times a day if on intensive insulin therapy or sliding scale insulin . An Insulin Administration policy, revised 09/14, read in part .The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin . 1. Resident #3 had diagnoses which included ischemic colon, type two diabetes mellitus, and high blood pressure. Skilled nurses' notes, dated 05/20/23 and 05/21/23, did not contain documentation that bowel sounds had been assessed. A Five Day Assessment, dated 05/22/23,…

    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 · Ecited before2023-10-13 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were available for administration for two (#3 and #4) of three sampled residents reviewed for pharmacy services. The DON stated there were 81 residents who resided in the facility. Findings: A Medication Ordering and Receiving from Pharmacy policy, revised 2018, read in part, .Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt . A admission Criteria policy, revised March 2019, read in part .Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: medication orders, routine care orders . 1. Resident #3 had diagnoses which included ischemic colon, right colectomy, type two diabetes mellitus, and high blood pressure. They admitted to the facility on [DATE]. A hospital Discharge Summary,…

    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 · E2023-01-10 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews the facility failed to: A. Provide baths/showers to dependent residents for four (#10, 31, 38, and #54), B. Provide incontinent care in a timely manner for one (#11) and, C. Provide nail care for one (#58) of nine sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility. Findings: A Shower/Tub Bath policy, revised October 2010, read in part, .The following information should be recorded on the resident's ADL record and/or in the resident's medical record .The date and time the shower/tub bath was performed .If the resident refused the shower/tub bath, the reason(s) why and the intervention taken . Notify the supervisor if the resident refuses the shower/tub bath . A Care of Fingernails/Toenails policy, revised 10/10, read in part, .Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the resident from accidentally scratching…

    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 · Ecited before2023-01-10 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to administer medications as ordered for one (#10) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility. Findings: Resident #10 had diagnoses which included hyperlipidemia, hypothyroidism, hypertension, major depressive disorder, GERD, and insomnia. Physician's orders, dated 12/05/22, documented the following: a. atorvastatin calcium 40 mg daily, b. levothyroxine 50 mcg daily c. lisinopril 10 mg daily, d. Mirtazapine 15 mg daily, e. omeprazole 20 mg daily, and f. Trazadone 50 mg daily. MARs, dated December 2022, documented the following: a. atorvastatin was blank one out of 26 opportunities, b. levothyroxine was blank six out of 26 opportunities, c. lisinopril was blank one out of 26 opportunities, d. Mirtazapine was blank one out of 26 opportunities, e. omeprazole was blank six out of 26 opportunities, and f. Trazadone was blank one out of 26 opportunities. On 01/09/23 at 2:18 p.m., the Wound…

    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 · E2023-01-10 · tag F0761 — failed to label and store drugs safely — pattern
    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 — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure medication carts remained locked when staff were not present for two of six medication carts observed. The DON identified six carts which contained medication in the facility. Findings: A Specific Medication Administration procedures, effective 04/2018, read in part, .Security: All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide . On 01/03/23 at 2:39 p.m., a medication cart on hall 100 was found to be unlocked and unattended. The cart was observed to contain, a bag of liquid medication, various creams, nebulizer liquids, bottles of medication, and insulin pens. On 01/03/23 at 2:41 p.m., LPN #7 stepped out of a resident room holding a specimen cup in a bag. LPN #7 states, Oh no, I'm in trouble. She stated she would be right back. LPN #7 passed the medication cart as she walked down the hall, LPN did not lock 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 · E2023-01-10 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and staff interview, the facility failed to obtain physician ordered labs for two (#10 and #58) of five sampled residents reviewed for laboratory services. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility. Findings: A Lab and Diagnostic Test policy, dated September 2012, read in parts, .The physician will identify and order diagnostic and lab testing .staff will process test requisitions and arrange for tests . 1. Resident #10 had diagnoses which included hypertension, acute kidney disease, and diabetes mellitus. A Physician's Order, dated 12/06/22, documented to collect a CBC and CMP weekly for two weeks then every other week. Lab: CBC and CMP weekly x 2 then every other week. There was no documentation the labs had been collected for the week of 12/12/22. On 01/09/23 at 2:18 p.m., the Wound Care nurse was asked if Resident #10's CBC and CMP had been collected during the week of 12/12/22. The Wound Care nurse, No, ma'am. 2. Resident #58 had diagnoses which included HTN, COPD and…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-10 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 interviews, the facility failed to have an effective administration to ensure: 1. the abuse policy was followed regarding allegations of misappropriation of pain medication signed out and not documented as administered for three (#36, 38 and #54) of five sampled residents reviewed for pain and controlled medication count records were verified by two licensed nurses when removed from circulation and placed into the drawer for controlled medications awaiting destruction for 10 (#11, 36, 43, 48, 66, 70, 127, 128,129, and #130) of 11 sampled residents reviewed for controlled medications awaiting destruction. 2. a resident had necessary intervention, monitoring, and care to prevent the development and worsening of an avoidable pressure injury/pressure ulcer for one (#11) of three sampled residents reviewed for pressure ulcers. 3. coordination of care with a third party dialysis center, failed to obtain weights as ordered, and failed to assess a resident after returning from…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to: a. provide personal care to residents in a manner which prevented cross contamination for four (#2, 11, 57 and #58) of four sampled residents observed during incontinent care, and b. ensure staff wore masks during a COVID-19 outbreak and the facilities community transmission rate was high. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility. Findings: A COVID-19 Resident and Staff Guidance/Outbreak Protocol policy, revised 10/25/22, read in part, .Guidance for Staff .When community transmission levels are high (surgical mask or N-95) . A Laundry and Bedding, Soiled policy, revised July 2009, read in part, .Place contaminated laundry in a bag or container at the location where it is used .Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items A Diarrhea and Fecal…

    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 · D2023-01-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure: A. resident's family was notified of a change in condition for one (#54) of one resident reviewed for notification of changes and B. the physician was notified in a timely manner of lab results for one (#21) of one resident reviewed for physician notification. The Resident Census and Conditions of Residents, dated 01/03/23, documented a census of 71 residents. Findings: 1. Resident #54 had diagnoses which included seizures, gastroparesis, and neuromuscular dysfunction of bladder. Resident #54's Quarterly Resident Assessment, dated 11/27/22, documented the resident required total assistance of one to two staff members for all ADL care. A Nursing Note, dated 12/23/22 at 9:21 a.m., read in part, resident has temp of 103; nurse practioner .called and message left on answering machine. A Nursing Note, dated 12/23/22 at 11:18 a.m., read in part, nurse practioner returned call and new order received for chest xray, cbc, cmp, rsv, and influzena [sic]…

    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 before2023-01-10 · 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

    Based on record review and interview, the facility failed to ensure neuro checks and post fall assessments were completed for one (#41) of one sampled residents reviewed for falls. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility. Findings: The facility's Neurological Assessment policy, revised October 2010, read in parts, .Neurological assessments are indicated .Following an unwitnessed fall . The facility's Assessing Falls policy, revised October 2010, read in parts, .Nursing staff will observe for delayed complications of a fall for approximately forty-eight .hours after an observed or suspected fall, and will document findings in the medical record . Resident #41 had diagnoses of unsteadiness on their feet, lack of coordination, weakness, and unspecified fall. Resident #41's Care Plan, revised 12/03/21, documented the resident was at risk for falls related to gait/balance problems, and decreased safety awareness. It documented for staff to follow the facility's fall protocol. Resident #41's quarterly…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-10 · tag F0698 — failed to provide proper dialysis care — isolated
    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, observation, and interview, the facility failed to ensure: A. coordination of care with a third party dialysis center, B. weights obtained as ordered, and C. a resident was assessed after returning from dialysis for one (#38) of one sampled resident reviewed for dialysis services. The Resident Census and Conditions of Residents report, dated 01/03/23, documented five residents received dialysis services. Findings: A Weight Assessment and Intervention policy, revised 09/08, read in part, .Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record . An End-Stage Renal Disease, Care of a Resident With policy, revised 09/08, read in part, .Residents with .ESRD .will be cared for according to currently recognized standards of care .Education and training staff includes .The type of assessment data that is to be gathered about the resident's condition as needed .Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including .How…

    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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
SIENNA EXTENDED CARE & REHAB LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/11/2009
HOLLAND, VERNIEIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF50%since 10/01/2025
HOLLAND, WHITNEYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 10/01/2025
MAHANEY, JULIEIndividualADP OF THE SNFsince 04/29/2025
RAJI, SHERIFFDEENIndividualADP OF THE SNFsince 08/21/2025

CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$8.3M
Net patient revenuemost recent cost report
-4.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 43%Medicare 35%Other / private 22%

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

$537per resident / day
operating cost
$16,339per month
≈ monthly operating cost
$516per 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 375534. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-21, 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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