Broadway Care & Rehab Center
1622 East Broadway, Muskogee, OK 74403 · For profit - Limited Liability company · 105 certified beds · (918) 683-2851 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $37,638 in federal fines (most recent 2025-03-06)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.3% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.3% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.6% | 3.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.5% | 4.7% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.3% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.9% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 85.5% | 94.6% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.7% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.8% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.9% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.8% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 15.9% | 74.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 34.0% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.9% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.06 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.03 | 2.96 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
34.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 67 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.9% 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 29 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 34.5%CMS range 22.9–44.8 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.6–14.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 37.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 37.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 17.2% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.0%CMS range 5.6–14.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.44 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 105 beds and averages 82.0 residents a day — about 78% occupied, or roughly 23 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 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 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 2.89 hrs/resident/day on weekends vs 4.35 on weekdays — 33% thinner on weekends — a notable drop. RN hours go from 0.26 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Kcited before2025-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 05/21/25, the OSDH determined an IJ situation was determined to exist related to accident hazards. 1.The facility failed to ensure hot liquids were served at a safe temperature. A resident assessment, dated 04/24/25, showed Resident #38 had severely impaired cognition and required supervision for eating. A May 2025 active physician's order summary showed Resident #38 had diagnoses which included dementia, delusional disorders, and blister unspecified thigh. An untitled document, dated 05/08/25, showed Resident #38 sustained a superficial burn injury on their upper left and right thigh after coming in contact with hot coffee. 2. The facility failed to ensure chemicals were properly secured when Resident #52 ingested Pine-Sol that was kept in a Styrofoam cup. A care plan, dated 03/07/25, showed Resident #52 had diagnoses which included intellectual disability, psychotic disorder, cerebral palsy, acute respiratory failure, and pneumonitis due to aspiration of vomit. A quarterly resident assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-03-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 record review and interview, the facility failed to access, monitor, and intervene for a resident at risk for pressure ulcers for 1 (#1) of 3 sampled residents reviewed for pressure ulcers. The director of nursing identified 11 residents residing in the facility had pressure ulcers. Findings: Resident #1 admitted on [DATE] with diagnoses which included dementia and cognitive communication deficit. Resident #1's Skilled Nursing Note, dated 01/16/25, showed the resident's skin was intact and no breakdown noted. Resident #1's admission assessment, dated 01/27/25, showed no pressure ulcers. The assessment showed Resident #1 was dependent of one to two persons with transfers and toilet hygiene. Resident #1's Physician's Order, dated 02/05/25, showed zinc oxide ointment 20%, apply to buttocks/sacrum topically every shift for prophylaxis skin integrity. Resident #1's Skin Observation Tool, dated 02/11/25, showed the resident had no skin breakdown or wounds. The tool showed to continue with pillow program (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 follow physician orders for 1 (#4) of 3 sampled residents reviewed for physician orders. The administrator identified 83 residents resided in the facility. Findings:A physician order, dated 04/21/25, showed the following medications were to be held starting 04/21/25:aspirin EC 9enteric coated) delayed release 81 mg (an antiplatelet medication used to prevent blood clots) for a procedure scheduled on 04/24/25.Plavix oral tablet 75 milligrams (antiplatelet medication used to prevent blood clots). A physician order, dated 04/24/25, showed Plavix )an anti-platelet) oral tablet was to be held on 04/26/25 for pacemaker placement. A review of the discontinued medications for Resident #4 showed these medications were not discontinued or held as ordered. A quarterly clinical assessment, dated 06/25/25, showed Resident #4 had diagnoses which included metabolic encephalopathy and cerebral ischemia. The assessment showed Resident #4 had a BIMS score of 6 which indicated severe cognitive impairment for decision making. On 07/30/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure that 1 (#1) of 3 residents reviewed for elopement received adequate supervision to prevent elopement. The Administrator reported a census of 83.Findings:A facility incident report, dated 7/22/23, showed Resident #1 eloped from the locked unit and was returned to the facility by local law enforcement. A tour of the facility was conducted on 07/22/23 to observe the corrective changes made in the window mechanisms. A review of the facility's investigation did not indicate how far the resident went after leaving the facility or the exact time frame the resident had left the facility. Resident records were reviewed for updated elopement status. Maintenance logs were reviewed for daily checks on windows in the locked unit and weekly checks on the windows in the rest of the building.A quarterly assessment, dated 07/14/25, for Resident #1 showed a diagnosis of unspecified dementia and BIMS score of 3 which indicated severe cognitive impairment.On 07/23/25 at 1:53 p.m., the administrator reported they were notified around…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure proper PPE was used for 1 (#24) of 3 sampled residents observed for EBP. The administrator identified 75 residents resided in the facility. Findings: On 05/29/25 at 8:39 a.m., the door frame to Resident #24's room was observed to have EBP signage and a tube feeding was observed hanging on a pole next to the resident's bed. On 05/29/25 at 8:57 a.m., LPN #1 entered Resident #24's room, closed the door, turned off the tube feeding, and checked placement with a stethoscope and syringe. LPN #1 had on gloves, but did apply a gown prior to accessing the resident's feeding tube. On 05/29/25 at 9:00 a.m., LPN #1 exited Resident #24's room to get water from a cart, returned to the resident's room, applied gloves, but still no gown was applied. PPE was observed inside the resident's room, on the back of the door, which included yellow gowns, gloves, and masks. A policy titled Enhanced Barrier Precautions, dated 05/15/24, read in part, The facility may expand the use of PPE [and] refer to the use of gown [and]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-06 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of resident to resident abuse for 1 (#2) of 3 sampled residents reviewed for abuse. The administrator identified 79 residents resided in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents .Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident. Resident #2 had diagnoses which included cognitive communication and unspecified intellectual disabilities. Resident #2's quarterly assessment, dated 10/30/24, showed a brief score for mental illness scored of three, indicating the resident's cognition was severely impaired. An unlabeled document, dated 11/19/24, read in part, Upon thorough investigation collecting statements from staff and 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.
- Potential for harm · Dcited before2025-03-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure infection control was maintained and EBP were followed during the provision of wound care for 1 (#6) of 3 sampled residents reviewed for pressure ulcers. The administrator identified 30 residents required enhanced barrier precautions. Findings: On 03/04/25 at 2:24 p.m., the wound care nurse was observed to enter Resident #6's room, wash their hands, don gloves, and provide wound care to Resident #6 who required EBP precautions. The wound care nurse did not wear a gown or mask to provide the care. An Enhanced Barrier Precautions, policy, dated 02/28/23, read in part, The Use of Gown & Gloves during High Contrast Resident Care Activities as indicated, when Contact Precautions do not otherwise apply, for Facility Residents with Wounds. Resident #6 admitted on [DATE] with diagnoses which included pressure ulcer of sacral region and resistance to multiple antimicrobial drugs. Resident #6's care plan, created on 02/10/25, showed enhanced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#1) of three sampled residents reviewed for abuse. The administrator identifed 75 residents resided in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: visitors, and any other individual Abuse: The willful infliction of injury, unreasonable confinement, intimidation with refusing physical harm, and pain. Abuse may be visitor-to-resident. 1. Resident #1 had diagnoses which included anxiety, repeated falls, nicotine dependence, and alcoholic polyneuropathy. A Quarterly Resident Assessment, dated 11/13/24, documented Resident #1's cognition was severly impaired. It documented the resident made themselves understood and was able to understand others. A Incident Report OSDH form, dated 11/18/24, read in part, At approximately 3:45 a.m. resident noted yelling out from room, nurse immediately went to room and noted resident being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0563 — failed to protect the right to visitors — isolatedHonor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
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's rights to receive visitors of the resident's choice for one (#1) of three residents reviewed for visitation. The DON reported the census was 71. Findings: A Visitation Policy, revised 02/17, read in part, .Our facility permits residents to receive visitors subject to the resident's wishes .The facility provides 24-hour access to all individuals visiting with the consent of the resident . Resident #1 had diagnoses which included hypertension and anxiety disorder. A progress note, dated 03/25/24 at 2:19 pm, documented that a friend of Resident #1 called and wanted to visit the resident. The note further documented the facility contacted Resident #1's POA and the POA did not want the friend to visit. The note also documented that the friend was called back by the facility and informed the POA did not want him to visit. A progress note, dated 04/03/24 at 9:26 am, documented that a friend of Resident #1 called and wanted to visit the resident. The note further documented the facility contacted Resident #1'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.
- Potential for harm · Ecited before2024-02-15 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for the need and an informed consent was obtained prior to the use of shepherds hook bed rails for two (#14 and #38) of two residents reviewed for bed rails. The administrator identified six residents whose beds were equipped with a bed rail of any type. Findings: A Bed Mobility Assistive Devices/Bed Rails policy, dated July 2018, read in parts, .If a bed rail is determined to be the most effective intervention for resident positioning/safety, the following requirements must be met: Bed/Bedrail assessment .Review of risks and benefits of bed rails with the resident or resident representative .Obtain informed consent prior to installation . 1. Res #14 had diagnoses which included heart failure, anxiety, and repeated falls. A physician order, dated 01/17/23, documented the resident may have a shepherd hook on bed for turning and repositioning. A quarterly assessment, dated 11/17/23, documented Res #14 was severely impaired in cognition, required supervision or touch assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to provide a bed hold policy to a resident prior to transfer for one (#49) of one resident reviewed for hospitalization. The administrator reported the census was 71. Findings: A notification of Bed Hold policy, dated December 2018, read in part .When a resident/patient is discharged to a hospital, the facility will notify the resident/patient and responsible party of bed hold days remaining .Document communication in the medical records . Resident #49 had diagnoses which included anxiety disorder and anemia. A physician order, dated 02/07/24 at 11:45 a.m., documented the resident was to be sent to the hospital for evaluation and treatment. A review of Resident #49's health record did not document the resident, or their representative had been given notice of the bed hold policy at the time of transfer. On 02/15/24 at 11:38 a.m., the administrator stated they did not have documentation the resident or their representative had been provided with a copy of the bed hold policy at the time of transfer.
- Potential for harm · Dcited before2024-02-15 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 level II PASRR referral was made to the Oklahoma Health Care Authority for one (#15) of four residents who were reviewed for PASARR. The administrator reported the census was 71. Findings: A Policy titled PASRR Determination, dated November 2023, read in part .Level 2 screens are conducted when necessary to insure that a beneficiary requires nursing facility level of care and/or specialized services within the nursing facility .It is the responsibility of the NF to ensure a Level II is completed on a beneficiary that meets previous criteria .A yes answer to any of the six questions in Section E of the LTC-300R form .Requires a Screening for Level II PASRR . Resident #15 had diagnoses which included unspecified intellectual disabilities and anemia. A PASRR level 1 form, dated 12/08/23, documented the social worker from the hospital Resident #15 was admitted from contacted the OHCA regarding a 30-day PASRR exemption letter as the resident was being admitted for skilled care. The level I PASRR also documented in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2024-02-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure that expired medications were removed from the medication room. The administrator reported the census was 71. Findings: A Medication Storage in the facility policy, dated April 2018, read in part, .Outdated, contaminated, or deteriorated medications .are immediately removed from inventory . On 02/15/24 at 9:23 a.m., a tour of the medication storage room for halls A and B was conducted with RN #1. A medication card containing ondansetron 4 mg for Resident #8 was observed to have an expiration date of 01/17/24. On 02/15/24 at 9:25 a.m., RN #1 stated the expired medication should have been removed from the medication room. On 2/15/24 at 9:30 a.m., the DON stated expired medications should be disposed of.
- Potential for harm · E2023-01-18 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an Oklahoma DNR consent form was: a. followed-up on when residents were admitted to the facility for #48. b. was signed by an eligible person to make decisions for Res #24. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included psychosis, dementia, and Parkinson's disease. A DNR form, dated 08/09/21, was in the resident's medical record. The DNR was not signed. The form documented a consent was obtained from a resident representative over the telephone. The DNR was completed while the resident was in the hospital. A physician order, dated 08/31/21, documented the resident's status was DNR. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and required total assistance with most activities of daily living. On 01/17/23 at 10:27 a.m., corporate nurse #1 stated there was no POA documentation for the resident in the record. She stated the staff should always follow-up when a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-18 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview the facility failed to ensure assessments accurately reflected the resident's status for four (#24, 27, 34, and #55) of 22 residents who were reviewed for resident assessments. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included psychosis, diabetes mellitus, dementia, and Parkinson's disease. A physician order, dated 10/21/22, documented to administer quetapine an (antipsychotic medication) 25mg at bedtime. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and required total assistance with most activities of daily living. The assessment documented the resident received an antipsychotic medication 7 days during the 7 day look back period. The assessment also documented the resident had not received antipsychotics on a regular basis. A care plan, last reviewed 12/07/22, did not document the resident was receiving an antipsychotic medication. On 01/17/23 at 4:39 p.m., the MDS coordinator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-18 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to update resident care plans to reflect the residents' current needs for three (#34, 55, and #62) of 18 residents whose care plans were reviewed. The facility failed to update the care plans to reflect: a. pressure ulcers for Res #34. b. the diet status of Res #55. c. behaviors including pilfering in other resident rooms for Res #62. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #62 had diagnoses which included myocardial infarction, anemia, and chronic lymphocytic leukemia of B-cell type. A nurse note, dated 08/05/22, documented the resident had been taking food off the other residents' plates. The note documented the resident had walked into another resident room and ate her dinner. A nurse note, dated 08/8/22, documented the resident was frequently found removing items from other resident rooms. A nurse note, dated 08/10/22, documented the resident wandered around the facility and into other resident rooms removing other 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.
- Potential for harm · E2023-01-18 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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, observation, and interview, the facility failed to provide medications to residents per physician order and facility policy for two (#20 and #40) of seven residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #20 had diagnoses which included diabetes mellitus. A physician order, dated 07/29/22, documented the facility was to administer Aspart Insulin by sliding scale with a FSBS of 0-150 = 0u; 151-200 = 2u; 201-250 = 4u; 251-300 = 6u, subcutaneously as needed for elevated blood sugar. A review of the resident's insulin administration records documented the resident had a FSBS of 279 on 10/21/22 and should have received 6 units of Aspart insulin. The records indicated the resident did not receive insulin at that time. A quarterly assessment, dated 12/16/22, documented the resident was severely impaired in cognition and received insulin seven days of the seven day assessment period. A care plan, last reviewed on 12/16/22, documented the resident had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-18 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to ensure a physician responded to the monthly pharmacist recommendations in a timely manner for three (#20, 21 and #24) of five residents sampled for unnecessary medications. The Resident Census and Conditions of Residents report documented 71 residents resided in the facility. Findings: The facilities Drug Regimen Review policy, dated December 2018, read in part .9. The resident's physician will be notified of the Pharmacy Recommendations. The facility will allow 10 days for the physician response to the recommendations. Any recommendations not completed within 10 days will be referred to the Medical Director . 1. Resident #21 was admitted to the facility on [DATE] and had diagnoses which included psychosis, paranoid schizophrenia, depression, abnormal involuntary movement, and anxiety disorder. A pharmacist MRR, dated 08/13/22, documented a recommendation to decrease Trazodone 50 mg to 25 mg. The MMR documented the physician agreed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-18 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Res #8 had diagnoses which included peripheral vascular disease, diabetes mellitus, and chronic pain syndrome. An admission assessment, dated 12/13/22, documented the resident was severely impaired with cognition and required extensive assistance with ADLs. The assessment documented the resident required oxygen and was on hospice care. A care plan could not be located in the resident record. On 01/11/23 at 3:25 p.m., Res #8 was observed on a low bed with oxygen at 2L per nasal cannula tubing, which was not dated. On 01/18/23 at 9:58 a.m., the corporate nurse consultant stated Res #8's care plan was one of three care plans that disappeared when electronic record updated. She stated she would continue to try and get the resident's care plan. On 01/18/23 at 11:10 p.m., the care plan coordinator stated the facility had called the electronic record company because the resident's care plan was gone. She stated a staff member who worked for the company was working to get the missing care plans back. She stated the update happened on 12/22/22 and there would be another update on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to implement their infection control policy related to water management for the prevention of Legionnaires' disease. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: A facility procedure, titled Legionnaires' Disease, dated September 2019, read in part, .Assess the facility's wear [sic] system risk of Legionella. Develop a water management strategies to reduce the risk of the growth and spread of Legionella if a risk assessment determines the facility to be at risk .1. Complete a facility assessment of the water system. A map/diagram will be developed which will show how the water enters and travels through the building. 2. Develop water management strategies for the facility's hot and cold water distributions system . On 01/18/23 at 2:58 p.m., the corporate administrator reported the facility did not know anything about water management for the prevention of Legionella. She confirmed the Legionnaires' Disease policy had not been implemented.
- Potential for harm · E2023-01-18 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, it was determined the facility failed to ensure an antibiotic stewardship program was consistently implemented for two (#21 and #24) of five residents whose medications were reviewed. The DON identified 22 residents who had received antibiotics in the last three months. Findings: 1. Resident #21 had diagnoses which included edema, infectious gastroenteritis and colitis, and urinary tract infection. An annual assessment, dated 04/04/22, documented the resident was moderately impaired with cognitive skills and received antibiotics every day of the seven day assessment period. A physician order, dated 10/31/22, documented the resident was to receive Keflex 500mg four times a day for seven days related to urinary tract infection. A nurse note, dated 11/25/22, documented the resident was complaining of left ear pain. A physician order, dated 11/25/22, documented the resident was to receive Augmentin 500/125 mg three times a day for ten days related to seasonal allergic rhinitis. On 01/17/23 at 9:27 a.m., the IP was interviewed and reported the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-18 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an abuse allegation was thoroughly investigated for one (#24) of one resident reviewed for allegations of abuse. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: The facility's abuse policy read in parts, .Investigation .d. Conduct interviews of alleged victim/resident representative .f. Conduct interviews of all actual/potential witnesses .h. Conduct record review to include .4. Complete Documentation of the investigation . An incident report form 283, dated 07/19/22, documented a resident reported to the administrator she had witnessed a CNA being rough with her roommate Res #24 while providing personal care. Res #24 had diagnoses which included psychosis, diabetes mellitus, Dementia, and Parkinson's disease. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and required total assistance with most activities of daily living. The documentation regarding the incident did not contain documented interviews…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-18 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 accurately capture the mental health diagnoses on a resident PASRR I assessment for one (#48) of one residents reviewed for PASRR. The Resident Census and Conditions of Residents form documented 36 residents had mental health diagnoses excluding dementia and depression. Findings: Res #48 was admitted with diagnoses which included unspecified mood disorder, agoraphobia with panic disorder, social phobia, post traumatic stress disorder, depression, and anxiety disorder. A PASRR level I assessment, dated 01/10/23, documented Res #48 did not have mental health diagnoses such as evidence of serious mental illness including possible disturbances in orientation or mood, a serious mental illness such as a schizophrenic, paranoid, panic, mood or other severe anxiety or depressive disorder, somatoform disorder, personality disorder, or other psychotic disorder, or another mental disorder that may lead to a chronic disability. On 01/18/23 at 9:06 a.m., the DON stated he did not think the resident had a pertinent mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 record review, observation, and interview, the facility failed to conduct routine pressure ulcer assessments and follow physician orders for pressure ulcer treatment for one (#34) of three residents sampled for pressure ulcers. The Resident Census and Conditions of Residents form documented five residents with pressure ulcers resided in the facility. Findings: Res #34 had diagnoses which included cellulitis of right lower limb and pressure ulcer of the sacral region. A physician order, dated 07/21/22, documented to cleanse sacral wounds with NS and pat dry; fill deficits with saline moistened gauze; apply calmaseptine cream to peri wound area; and cover daily related to pressure ulcer of sacral region, stage IV. A wound note, dated 10/14/2022 at 2:49 p.m., documented the resident had two sacral wounds which measured 0.4 x 0.3 x 0.3 cm and 4.0 x 0.8 x 0.3 cm. The EHR documented on 10/15/22 the resident went to the hospital. A care plan, last reviewed 10/18/22, documented the resident had damage to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure respiratory orders were followed for one (#8) of one resident sampled for respiratory care. The Resident Census and Conditions of Residents form documented 23 residents with respiratory treatments resided in the facility. Findings: Res #8's physician order, dated 12/20/22, documented oxygen at two to three liters continuously every shift to maintain oxygen saturation greater than 90% for shortness of breath. An admission assessment, dated 12/13/22, documented the resident was severely impaired with cognition and required extensive assistance with ADLs. The assessment documented the resident required oxygen and was on hospice care. A care plan could not be located in the resident record. The December 2022 TAR, did not document the resident's oxygen saturation for nine of 31 shifts as ordered by the physician. The January 2023 TAR, did not document the resident's oxygen saturation for 22 of 33 shifts as ordered by the physician. On 01/11/23 at 3:25 p.m., Res #8 was observed on a low bed with oxygen at 2L…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-18 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure a resident was assessed for the need, an order was obtained, an informed consent was obtained, and a care plan was completed, prior to the use of a shepherds hook bed rail, for one (#27) of one resident reviewed for bed rails. The administrator identified eight residents whose beds were equipped with a bed rail of any type. Findings: Res #27 had diagnoses which included dementia, retention of urine, muscle wasting and atrophy, and abnormalities of gait and mobility. A post fall progress note, dated 11/16/22, documented the resident had experienced an unwitnessed fall in her room. The resident slid from her bed and her head was stuck on the shepherds hook causing a skin tear. The post fall note documented the resident did not have to go to the hospital from the injury. A quarterly assessment, dated 12/08/22, documented Res #27 was severely impaired in cognition, required extensive assistance with ADLs, was always incontinent of urine, and had not fallen. On 01/11/23 at 12:22 p.m., the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-18 · tag F0849 — isolatedArrange 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 — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to designate a facility staff member as an interdisciplinary team member to work with the hospice representatives and failed to ensure the hospice agreement documented the required components for one (#27) of one resident reviewed for hospice services. The Resident Census and Conditions of Residents form documented 12 residents who resided in the facility received hospice services. Findings: A physician order for Res #27 documented to admit the resident to hospice services for a diagnosis of Lewy Body Dementia. The hospice agreement between the hospice and the facility was reviewed and did not document a provision stating the facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the facility became aware of the alleged violation. The agreement did not document a provision for the hospice to provide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-18 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment and failed to ensure when rails and mattresses are purchased separately from the bed frame the bed rails, mattress, and bed frame are compatible. The administrator identified eight residents whose beds were equipped with a bed rail of any type. Findings: Res #27 had diagnoses which included dementia, retention of urine, muscle wasting and atrophy, and abnormalities of gait and mobility. A post fall progress note, dated 11/16/22, documented the resident had experienced an unwitnessed fall in her room. The resident slid from her bed and her head was stuck on the shepherds hook causing a skin tear. The post fall note documented the resident did not have to go to the hospital from the injury. On 01/11/23 at 12:22 p.m., the resident was observed in her room laying on a mattress with bolsters. A fall mat was observed at the side of the bed and a geri chair…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$37,638 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $8,044 — penalty dated 2025-03-06
- $29,594 — penalty dated 2025-03-06
- Medicare payment denial — starting 2025-06-06 for 33 days
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.
Part of a chain
This home belongs to MGM HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.3 | -1.3 vs chain |
| Health inspection | 1 of 5 | 2.4 | -1.4 vs chain |
| Staffing | 2 of 5 | 1.7 | +0.3 vs chain |
| Quality measures | 3 of 5 | 3.6 | -0.6 vs chain |
The other 26 homes this chain runs (chain average 2.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OK SNF HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/14/2024 |
| OK SNF INVESTMENTS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/14/2024 |
| OK4 OPCO, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/30/2024 |
| CDW INVESTMENTS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/30/2024 |
| JFB OK TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/14/2024 |
| MM ACQUISITIONS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/30/2024 |
| NDF INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/30/2024 |
| SOUTHEAST VENTURES TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/14/2024 |
| JACKSON, BRITTONEY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/14/2024 |
| LAMBERT, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/14/2024 |
| KOSS, ALLEN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/16/2025 |
| BROADWAY REALTY, LLC | Organization | ADP OF THE SNF | — | since 05/14/2024 |
| OK4 PROPCO, LLC | Organization | ADP OF THE SNF | — | since 10/30/2024 |
CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
10 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.
This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375146. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-29, 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 →
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