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Pleasant Valley Health Care Center

1120 Illinois Street, Muskogee, OK 74403 · For profit - Corporation · 101 certified beds · (918) 682-5391 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$20,049 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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 $20,049 in federal fines (most recent 2024-08-20)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (61%) runs well above the national median (45%)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3101 Okmulgee · (918) 687-4411 · Call to confirm hours
Pharmacy
Homeland0.6 mi
1300 S York St · (918) 683-2854 · Call to confirm hours
Grocery
615 N York St · (918) 682-1194 · Call to confirm hours
Park
1050 Gulick St · (918) 684-6302 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased21.9%13.6%15.4%worse
Long-stay residents who lose too much weight7.6%3.3%5.4%worse
Long-stay residents with a catheter left in their bladder1.6%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.3%2.8%2.0%worse
Long-stay residents with depressive symptoms1.4%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 injury4.9%4.7%3.3%worse
Long-stay residents whose ability to walk worsened20.6%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication26.6%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine95.8%94.6%95.3%typical
Long-stay residents with pressure ulcers5.1%4.7%4.7%typical
Long-stay residents with worsening bladder/bowel control22.9%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.7%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine58.4%74.1%79.4%worse
Short-stay residents rehospitalized after admission31.0%27.3%22.6%worse
Short-stay residents with an outpatient ER visit13.7%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.362.311.67worse
Long-stay outpatient ER visits per 1,000 resident days2.142.961.80worse

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.

43.4% 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 76 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.4%U.S. median 51.5%
Got home and stayed home
13.6%U.S. median 10.7%
Went back to hospital
55.2%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 55.2% 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 58 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 0.32 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 SNF43.4%CMS range 33.7–56.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.6%CMS range 9.0–18.910.7%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 discharge55.2%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 discharge48.3%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 discharge51.7%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 identified84.8%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 setting97.1%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 discharge100.0%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 stay3.3%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 worsened7.6%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 hospitalization9.1%CMS range 5.9–13.37.1%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

0.24
RN hours/ resident / day
0.91
LPN hours/ resident / day
2.97
Aide hours/ resident / day
4.12
Total nurse hours/ resident / day
0.17
RN hoursweekends
61.0%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 101 beds and averages 78.2 residents a day — about 77% 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 4.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.97 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.40 hrs/resident/day on weekends vs 4.42 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.28 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%.

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

4
deficiencies at the latest standard inspection (2026-06-11)
14
at the previous standard inspection (2024-08-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · J2024-08-20 · 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

    On 08/16/24 at 9:35 a.m., the Oklahoma State Department of Health identified the presence of an immediate jeopardy related to the facility failed to evaluate Residents #51 and #18 for the capacity to consent to sexual activity. Resident #18 had known sexually inappropriate behaviors and there was no evidence the facility identified these events as sexual abuse or evaluated the resident's capacity to consent. A Progress Note, dated 06/21/24 at 7:16 p.m., documented Resident #51 was observed with their legs opened and Resident #18 was sitting in front of Resident #51, rubbing on Resident #51's vagina. The nurse told the residents they could not do that. The nurse observed them kissing, went to speak with Resident #51, who was leaned forward while trying to pull their pants down, and Resident #18 had partial of their penis out. The nurse told them they could not do that in the hallway. On 08/16/24, there had been no documentation of evaluation of capacity to consent, care plans or assessments for Residents #51 and #18 regarding sexual activity. On 08/16/24 at 11:10 a.m., the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a fall intervention to toilet a resident every hour was implemented for 1 (Resident #85) of 3 sampled residents reviewed for falls.Findings included: An admission Record indicated the facility admitted Resident #85 on 04/16/2026. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure. Resident #85's Baseline Care Plan, with an admission date of 04/16/2026, indicated the resident required one person physical assistance for toilet use, was always incontinent of urinary continence, frequently incontinent of bowel continence, and had a history of falls. Resident #85's incident report dated 04/16/2026, indicated the resident was on the floor in front of their wheelchair in front of the nurses' station due to an attempt to stand. Per the incident report, the resident slipped, fell, and landed on their buttocks in front of their wheelchair. The incident report indicated…

    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 · D2026-06-11 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure a licensed practical nurse (LPN) knew how to prime an insulin pen for 1 (Resident #7) of 6 residents observed for medication administration.Findings included: An undated facility document titled, Job description for Charge Nurse, specified Job Knowledge: 1. Knowledge of procedures and techniques necessary to administer medications and treatment as prescribed by the physician. An undated facility document titled, Staff education Policy signed by the Director of Nursing (DON), indicated It is the policy of this facility to perform Staff education or in-services based on the required annual in-services by the state and any additional training that is needed by the staff on an as need basis. An admission Record revealed the facility admitted Resident #76 on 11/16/2020. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD)…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, facility policy review, and the manufacturer's guidelines, the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 3 medication errors out of 34 opportunities, which yielded a medication error rate of 8.82% for 2 (Resident #76 and Resident #7) of 6 residents observed for medication administration. Findings included: A facility policy titled, Medication Administration, revised 06/03/2025, revealed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy specified, 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 1. The manufacturer's guidelines for the Lantus pen, with a copyright date of 2022, indicated, Step 3. Perform a safety test * Dial a test dose 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's supplemental oxygen tubing was stored in a plastic bag when not in use for 1 (Resident #41) of 1 sampled resident reviewed for respiratory care.Findings included: A facility policy titled, Oxygen Administration, revised 06/03/2025, indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy specified, e. Keep delivery devices covered in plastic bag when not in use. An admission Record indicated the facility admitted Resident #41 on 10/02/2023. According to the admission Record, the resident had a medical history that included a diagnosis of acute respiratory failure with hypoxia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/03/2026, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #41's Care…

    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 · E2024-08-20 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facilty failed to ensure staff members assisted residents with eating in a dignified manner for two (#12 and #75) of nine sampled residents observed during meal service in the assisted dining room. The DON identified 15 residents who required feeding assistance resided in the the facility. Findings: A Promoting/Maintaining Resident Dignity During Mealtimes policy, revised 07/04/24, read in part, It is the practice of this facility to treat each resident with respect and dignity .All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes .All staff will be seated, if possible, while feeding a resident . 1. Resident #12 had diagnoses which included vascular dementia and obsessive-compulsive behavior. An Annual Resident Assessment, dated 06/09/24, documented Resident #12 had severe cognitive impairment and was dependent on staff for the task of eating. On 08/13/24 at 12:14 p.m., CMA #3 was observed standing over Resident #12 and giving them a bite of their lunch…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-20 · tag F0574 — pattern
    The resident has the right to receive notices in a format and a language he or she understands.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure information to file a formal complaint to the state agency and ombudsman were readily available to 10 of 10 residents that attended the resident group interview. The Administrator reported the census was 83. Findings: On 08/14/24 at 3:15 p.m., ten residents were asked if they knew their Ombudsman. several of the residents questioned what was an Ombudsman. The residents were introduced, then asked if they were familiar with where information was posted to call the ombudsman if they had a concern or complaint. They stated they did not know but the information may be on the bulletin board on C Hall. The residents were asked if they knew how to report a complaint to the state survey office. They stated they did not know, the information may have been posted on the bulletin board on C Hall. On 08/14/24 at 3:46 p.m., the bulletin board on C Hall was observed to have the information to report a complaint to the state office and posting of the Ombudsman. The forms were near the top of the bulletin board, with the bottom 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-20 · tag F0577 — pattern
    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

    Based on observation and interview, the facility failed to ensure past survey results were readily available to residents to review for 10 of 10 residents that attended the resident group interview. The Administrator reported the census was 83. Findings: On 08/14/24 at 3:15 p.m., ten residents were asked if they knew where the previous survey results were posted and if the reports were readily available to them, without having to request the information The residents stated they did not know they could look at the reports and did not know where to locate the previous reports. On 08/14/24 at 3:46 p.m., the bulletin board on C Hall was observed to have a binder labeled, Survey Results, in a file bin mounted to the wall. The lower part of the bin was approximately five feet above the floor. The binder was attached to a chain that limited the binder to be lowered approximately three feet above the floor. On 08/14/24 at 3:50 p.m., the Administrator was asked if the previous survey results were readily available to the residents to review, without the assistance of staff. They stated the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-20 · tag F0609 — failed to report abuse allegations — pattern
    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 interview and record review, the facility failed to ensure the results of abuse investigations were submitted to the State within 24 hours for three (#15, 44, and #51) of five residents reviewed for abuse. The Administrator identified 83 residents resided in the facility. Findings: Resident #15 had diagnoses which included cognitive communication deficit and chronic kidney disease, stage 3. Resident #15's admission assessment, dated 05/22/24, documented Resident #15's cognition was intact. An Initial State Reportable Incident form, faxed on 07/08/24 at 4:37 p.m., documented CNA# 5 reported to administration Resident #15 had reported to them that on 07/03/24 CNA #4 had called Resident #15 an expletive word in the shower room. A Final State Reportable Incident form, faxed on 07/11/24 at 12:57 p.m., documented CNA #4 was immediately put on a three day suspension for verbal abuse allegation during this investigation. All staff were immediately in-serviced over abuse on 07/08/24. On 08/14/24 at 1:17 p.m., RN #1 stated the facility policy for reporting abuse was to report verbal…

    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 · E2024-08-20 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. Resident #44 had diagnoses to include mild intellectual disabilities, vascular dementia, hearing loss, visual loss, behavioral and emotional disorder with childhood onset, schizophrenia, and bipolar. A Quarterly Assessment, dated 07/19/24 documented Resident #44 had moderate cognitive impairment, displayed verbal behavioral symptoms toward others and required some substantial to maximum assistance with ADLs. An Incident Report Form, dated 06/26/24 documented a hospice nurse reported Resident #44 stated a staff member was too rough with Resident #44. The resident had reported they had urinated on themselves in the dining room at lunch and the aide had to take the resident out of the dining room to provide care. Resident #44 stated They just jerked me around . The investigative file, contained documented of two Nurse Aides, a visitor, the resident's room mate, and a hospice nurse were interviewed. There was no documentation other staff or residents in the facility had been interviewed to ensure the safety of all residents. On 08/15/24 11:35 a.m., in the presence of 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 · Ecited before2024-08-20 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to revise care plans for two (#18 and #51) of 21 residents reviewed for care plans. The Administrator identified 83 residents resided in the facility. Findings: A Care Plan Revisions Upon Status Change policy, revised 07/02/24, read in part, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change .The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change .The care plan will be updated with the new or modified interventions . Resident #18 had diagnosis which included unspecified dementia. Resident #18's quarterly assessment dated , 04/20/24, documented Resident #18's cognition was severely impaired. A Behavior Note, dated 09/20/19 at 5:24 p.m., documented, Another resident informed this nurse that resident was in hallway touching penis. List Interventions Attempted: Educated [Resident #18] that resident will need to go inside room in private to do so. A Behavior Note,…

    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
Show the remaining 17 citations
  • Potential for harm · E2024-08-20 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week. The Administrator identified 83 residents resided in the facility. Findings: On 08/14/24 at 10:58 a.m., Human Resource #1, provided the requested RN hours for May, June, and July. Review of the RN time punch details documented, the facility did not have RN coverage for eight consecutive hours on the following dates: a. 05/04/24 - 7.68 hours worked, b. 05/05/24 - 7.72 hours worked, c. 05/12/24 - 7.47 hours worked, d. 05/18/24 - 7.45 hours worked, e. 05/19/24 - 7.43 hours worked, f. 05/27/24 - 7.80 hours worked, g. 06/08/24 - 7.60 hours worked, h. 06/23/24 - 7.67 hours worked, i. 07/05/24 - 4.93 hours worked, j. 07/06/24 - 7.60 hours worked, k. 07/07/24 - 7.53 hours worked, l. 07/13/24 - 7.45 hours worked and, m. 07/26/24 - 7.47 hours worked. On 08/15/24 at 11:37 a.m., Human Resource #1 stated if the facility did not have RN coverage, the DON or ADON would need to come in to cover. On 08/15/24 at 11:48 a.m., Human Resource #1 stated the dates…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-20 · 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 follow their policy to administer medications via enteral tube for one (#13) of one sampled resident reviewed for medication administration via gastrostomy tube. The Administrator stated 83 residents resided in the facility. The Resident Matrix, dated 08/12/24, documented four residents with a gastric tube resided in the facility. Findings: A Medication Administration via Enteral Tube policy, dated 07/02/24, documented, .flush enteral tube with water per orders prior to administering medications .dilute the solid or liquid medication as appropriate and administer using a clean oral syringe .Flush tube again with water per orders taking into account resident's volume status .repeat with the next medication .flush the tube with a final flush of water . Physician Orders for Resident #13 included: a. On 07/06/23, may crush medications; b. On 08/08/23, clopidogrel bisulfate 75 mg by mouth every day for hypertension; lactulose 10 gm/15 ml give 30 ml by mouth daily; Mylanta maximum strength oral suspension…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-20 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 37 medications opportunities were observed, with three errors, for a total error rate of 8.11%. This affected two (#13 and #43) of six residents observed during the medication administration. The Administrator stated 83 residents resided in the facility. Findings: 1. A Physician Order, dated 03/09/24, documented Resident #43 was to be administered a chewable aspirin one time a day for atherosclerotic heart disease. On 08/14/24 at 8:50 a.m., CMA #1 prepared and administered oral medications for Resident #43, to include a chewable aspirin as ordered. CMA placed the chewable aspirin in the same medication cup with other medications for a total of 10 medications. CMA #1 did not provide instruction to Resident #43 regarding the chewable aspirin to be chewed and not swallowed. 2. Physician Orders for Resident #13 included: a. On 07/06/23, may crush medications; b. On 08/08/23, administer Mylanta Maximum Strength oral suspension by mouth two times a day…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-20 · 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: 1. ensure bare hand contact with food did not occur during the lunch meal service. 2. monitor the dish washing machine to ensure proper sanitation was being conducted. Findings: A Food Service policy, undated, read in part, .All staff in the dining room will wash/sanitize hands with any resident contact, touching other surface or contact with your own person before serving a resident meal tray . 1. Resident #75 had diagnoses which included unspecified dementia and mild neurocognitive disorder. A Quarterly Resident Assessment, dated 07/27/24, documented Resident #75 had severe cognitive impairment and required supervision or touching assistance for the task of eating. On 08/13/24 at 12:19 p.m., CNA #1 picked up Resident #75's slice of bread with their bare hands and asked the resident if they wanted a bite. On 08/13/24 at 12:30 p.m., CNA #1 picked up Resident #75's slice of bread with their bare hands and tried to feed it to them. The resident took the piece of bread from CNA #1 and started feeding…

    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 · Ecited before2024-08-20 · 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. handle soiled linens in a manner that prevented cross contamination for one (#14) of one sampled resident observed during wound care; and b. ensure enhanced barrier precautions were utilized when accessing a resident's gastric tube for one (#13) of one sampled resident observed with a gastric tube. The Administrator identified 83 residents resided in the facility. The Resident Matrix, dated 08/12/24, documented four residents with a gastric tube resided in the facility. Findings: A Laundry Services policy, undated, read in part, .All soiled linen should be bagged or put into carts at the location where used .If laundry barrels are used, all linens should be bagged . An Enhanced Barrier Precautions policy, dated 07/24/24, read in part, .Enhanced barrier precautions .(EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .enhanced barrier precautions .for…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-20 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure Resident Assessments were accurately coded for two (#58 and #85) of 21 residents reviewed for assessments. The Administrator identified 83 residents resided in the facility. Findings: 1. Resident #58 had diagnoses which included dysphagia following cerebral infarction. A Physician Order, dated 07/17/23, documented admit to hospice for CVA. An Annual Resident Assessment, dated 07/18/24, did not document hospice care was received while the resident was at the facility. On 08/15/24 at 2:16 p.m., MDS Coordinator #1 stated they started with evaluating the resident's cognition, went through the resident's chart, pain, completed all of their interview questions, and reviewed progress notes and assessments to ensure Resident Assessments were accurately coded. On 08/15/24 at 2:17 p.m., MDS Coordinator #1 stated the life expectancy less than six months section and hospice should be checked yes when a resident received hospice care. They stated Resident #58 was receiving hospice care. On 08/15/24 at 2:19 p.m., 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-20 · tag F0772 — isolated
    Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
    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 physician ordered labs were obtained for one (#14) of 12 sampled residents reviewed for lab services. The Administrator identified 83 residents resided in the facility. Findings: A Laboratory Services policy, reviewed 07/02/24, read in part, .The facility must provide or obtain laboratory services when ordered .The facility is responsible for the timeliness of the services. Resident #14 had diagnoses which included stage four pressure wound of the left heel. Wound Evaluation and Management Summary notes, dated 05/15/24, documented HBA1C recommended. The note was signed by the Wound Care Physician. Wound Evaluation and Management Summary notes, dated 05/22, 05/29, 06/05, 06/12, 06/19, 06/28, 07/17, 07/24, 07/31, 08/07, and 08/14/24 documented the HBA1C was pending. The notes were signed by the Wound Care Physician. There was no documentation the HBA1C was ever obtained. On 08/15/24 at 8:40 a.m., the ADON was asked to clarify the recommendation of a HBA1C on Resident #14's wound care notes. On 08/15/14 at 9:32 a.m.,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-07-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure food was stored in a sanitary manner and dishes were dried completely before storing them. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: On 07/12/23 at 11:44 a.m., an initial tour of the kitchen was conducted. The following were observed: a. A scoop was observed stored in a large container which was filled with flour. b. Condensation was on plastic containers which were stacked on a shelf. On 07/12/23 at 11:49 a.m., the DM stated scoops should never be left inside any container which stored food. The DM stated the plastic containers should not have been stacked while drying. The DM stated containers should have been left on a shelf to dry and once completely dry then stacked.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-18 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure care plans were updated to meet residents' current needs for three (#14, 19, and #47) of 25 sampled residents whose care plans were reviewed. The facility failed to ensure: a. Res #47's care plan was updated with new fall interventions. b. Res #19's care plan was updated with new dialysis orders. c. Res #47 and #14's care plans had input by the required staff members. d. the facility held the required care plan meetings for Res #47 and #14. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: 1. Res #14 had diagnoses which included CHF, dementia, and anxiety disorder. An admission assessment, dated 11/22/23, documented the resident was severely impaired in cognition, required extensive assistance with most ADLs, and did not walk. The assessment did not document the resident had fallen and the CAA did not trigger falls for care planning. The resident's records did not document a care plan meeting occurred after the completion of the admission…

    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 · E2023-07-18 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Res #11 had diagnoses which included abnormalities of gait and mobility, lack of coordination, muscle weakness, difficulty in walking, muscle wasting and atrophy, and morbid obesity. A care plan, dated 09/05/2016, documented the resident used positioning bar for repositioning and transfer related to obesity and arthritis. A care plan, dated 12/01/2017, documented the resident would be free of injuries related to positioning bars. A quarterly assessment dated [DATE], documented the resident's cognition was intact and required minimal to limited assistance with ADLs. A five day assessment, dated 05/24/23, documented the resident's cognition was intact and required limited to no assistance with ADLs. On 07/12/23/ at 4:34 p.m., an observation was made of the resident's bed. Grab bars were observed secured to each side of the resident's bed. On 07/17/23 at 09:45 a.m., an interview was conducted with the MDS Coordinator #1 and the MDS coordinator stated the rails on the bed were positioning bars not bed rails. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-18 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure the medication error did not exceed five percent. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: 1. A physician order for Res #72, dated 07/10/23, documented the facility was to administer two drops of ciprfloxacin HCL ophthalmic solution three percent in the resident's right eye four times a day for seven days due to an eye infection. On 07/13/23 at 2:33 p.m., CMA #1 was observed to place two drops of ciprofloxin ophthalmic solution in both eyes of Res #72. On 07/13/23 at 2:36 p.m., CMA #1 stated she started putting the drops in both eyes yesterday. On 07/14/23 at 1:13 p.m., the DON confirmed the order for stated to administer the eye drops in the right eye. 2. Res #49's physician order documented to administer one 20 mEq of potassium chloride twice daily. On 07/14/23 at 7:57 a.m., CMA #2 was observed to administer two tablets of 20 mEq potassium chloride to Res #49. The medication card documented to administer two tablets of 20 mEq 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-18 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, it was determined the facility failed to implement an effective pest control program for the facility. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: The facility pest control records for the previous six months documented the pest control service had treated the facility monthly for cockroaches, rodents, bed bugs, and flies. There was no documentation provided by the facility for pest for the month of June 2023. On 07/12/23 at 11:44 a.m., during the initial tour of the kitchen a live cockroach was observed crawling across the floor while the staff was preparing to serve the noon meal. On 07/12/23 at 12:49 p.m., a live cockroach was observed crawling on the dining room floor while residents were eating their meal. On 07/12/23 at 01:25 p.m., the DM stated the facility had a pest control company come in and spray every two weeks. The DM stated the company was spraying every week but had just changed it to every two weeks.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-18 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and interview, the facility failed to ensure a resident's DNR form was signed by an individual with the authority to do so for one (#69) of three residents reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 48 residents had advanced directives. Findings: Res #69 had diagnoses which included Alzheimer's disease. A Durable General Power of Attorney form, dated [DATE], read in part, .28. Restrictions on Agent's [NAME] .f. My agent cannot execute on my behalf an Advanced Directive for Health Care, living will or other, similar instrument . An OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM, dated [DATE], was signed by the individual who was documented as the resident's agent in the Durable General Power of Attorney form dated [DATE]. A quarterly assessment, dated [DATE], documented Res #69 was severely impaired in cognitive skills, required extensive to total assistance with ADLs, and was receiving hospice care. A care plan, reviewed on [DATE], documented…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-18 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to OHCA for a PASRR Level II evaluation for one (#41) of two residents reviewed for PASRR. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility. Findings: A PASRR level one document for Res #41, dated 02/23/15, documented the resident had no mental illness, history of mental illness, or sign of mental illness. The resident's EHR documented Res #41 received diagnoses of recurrent major depressive disorder, unspecified mood affective disorder, and generalized anxiety disorder. The resident's EHR documented Res #41 received a diagnosis of pseudobulbar affect on 08/07/20. The resident's EHR documented Res #41 received a diagnosis of bipolar disorder on 08/11/21. A significant change assessment, dated 06/05/23, documented Res #41 was moderately impaired in cognition, required extensive to total assistance with ADLs, and was not considered by the state level PASRR level II process to have serious mental illness. The assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents received supervision and assistance to prevent falls for one (#47) of four residents sampled for falls. The administrator identified 54 residents who had fallen in the previous six months. Findings: Res #47 had diagnoses which included acute and chronic respiratory failure with hypoxia, lack of coordination, abnormalities of gait and mobility, muscle weakness, osteoarthritis, anemia, and anoxic brain damage. The care plan documented an intervention, dated 12/04/17, to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan intervention included to be sure the staff promptly responded to all requests for assistance. An incident report, dated 11/27/22, documented the experienced a fall in their room between their bed and their room mates bed. The new intervention was documented as place a sign on the resident's wall reading Call, Don't Fall to remind the resident to use her call light. The resident's care plan 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-18 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a medication regimen review conducted by the consultant pharmacist and agreed on by the physician was acted on for one (#42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 81 residents resided in the facility. Findings: Res #42 had diagnoses which included abnormal weight loss, sarcopenia, and dementia without behavioral disturbances. A physician order, dated 09/14/22, documented to administer mirtazipine (an antidepressant sometimes used to increase a resident's appetite) 7.5 mg one tablet at bedtime for appetite. A medication regimen review, dated 02/10/23, documented a request to decrease mirtazapine from 7.5 mg. A physician response, dated 02/21/23, documented to reduce the resident's dose of mirtazapine from one tablet to 1/2 a tablet at bedtime. A significant change assessment, dated 05/19/23, documented the resident was severely impaired in cognition and required extensive assistance with most ADLs. The assessment documented the resident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a psychotropic medication was not administered in excessive dosage for one (#42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 46 residents who resided in the facility received antidepressant medications. Findings: Res #42 had diagnoses which included abnormal weight loss, sarcopenia, and dementia without behavioral disturbances. A physician order, dated 09/14/22, documented to administer mirtazipine (an antidepressant sometimes used to increase a resident's appetite) 7.5 mg one tablet at bedtime for appetite. A medication regimen review, dated 02/10/23, documented a request to decrease mirtazapine 7.5 mg. A physician response, dated 02/21/23, documented to reduce the resident's dose of mirtazapine from one tablet to 1/2 a tablet at bedtime. A significant change assessment, dated 05/19/23, documented the resident was severely impaired in cognition and required extensive assistance with most ADLs. The assessment documented the resident received…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$20,049 in federal fines across 1 penalty.

  • $20,049 — penalty dated 2024-08-20

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

Who owns this facility

Owner / managerTypeRoleSince
NEVITT, DANNYIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
ANDERSON, WILLIAMIndividualADP OF THE SNFsince 01/16/2025
LOWRIMORE, MORGANIndividualADP OF THE SNFsince 01/16/2025

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$7.2M
Net patient revenuemost recent cost report
-9.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 61%Medicare 9%Other / private 30%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$290per resident / day
operating cost
$8,804per month
≈ monthly operating cost
$265per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375451. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-11, 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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