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24th Place

600 24th Avenue Southwest, Norman, OK 73069 · For profit - Individual · 89 certified beds · (405) 329-6771 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Dec 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$23,179 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2024
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $23,179 in federal fines (most recent 2025-12-02)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (75%) runs well above the national median (45%)
  • 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.

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

Location & what’s nearby

Urgent care / clinic
2121 W Main St · (405) 343-6793 · Call to confirm hours
Pharmacy
2296 W Main St · (405) 212-3177 · Call to confirm hours
Grocery
Aldi0.4 mi
2440 W Main St · (855) 955-2534 · Call to confirm hours
Park
Typically dawn to dusk

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

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 increased23.1%13.6%15.4%worse
Long-stay residents who lose too much weight3.1%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.6%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.1%2.8%2.0%better
Long-stay residents with depressive symptoms4.3%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 injury2.8%4.7%3.3%better
Long-stay residents whose ability to walk worsened23.2%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication33.2%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.7%94.6%95.3%typical
Long-stay residents with pressure ulcers4.1%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control20.4%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table22.8%17.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication5.7%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine50.0%74.1%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.472.311.67better
Long-stay outpatient ER visits per 1,000 resident days1.882.961.80typical

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.

0.05U.S. median 0.31
Therapy hours / resident / day
0.01hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 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

0.12
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.19
Aide hours/ resident / day
3.04
Total nurse hours/ resident / day
0.13
RN hoursweekends
75.3%
Total nursing turnover
100.0%
RN turnover

How full it usually is: this home is certified for 89 beds and averages 73.5 residents a day — about 83% occupied, or roughly 16 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.12 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.87 hrs/resident/day on weekends vs 3.10 on weekdays — 8% thinner on weekends. RN hours go from 0.12 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 75% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-10-02)
6
at the previous standard inspection (2024-05-09)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

33 citations, most serious first. The 14 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · J2025-10-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On [DATE], an IJ situation was determined to exist related to the facility's failure to provide oxygen as ordered by the physician. Resident #77 was found unresponsive and without oxygen on [DATE]. The resident expired in the facility. Resident #77 had a physician order for continuous oxygen at 2 liters per minute per nasal cannula. On [DATE] at 3:01 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 3:12 p.m., the administrator was notified of the IJ and provided the IJ template. On [DATE] at 12:33 p.m., an amended plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Immediate Plan Of RemovalFacility revied [sic] all patients with oxygen orders on 9-29-2025 by 5:00 p.m. to ensure appropriate physician orders are in place, pulse ox, oxygen saturation, and liters ordered per patients is monitored Q shift per policy, and documentation is completed in each resident Emar Q shift. All patients…

    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
  • Actual harm · G2025-12-02 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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's orders were followed for enteral feeding for 1 (#1) of 1 resident sampled for enteral feeding.The administrator identified 72 residents resided in the facility. Findings:On 12/01/25 at 10:30 a.m., Resident #1 was observed resting in bed with their eyes open.A facility policy titled Enteral Tube Feeding via Syringe (Bolus), dated November 2018, read in part, Verify that there is a physician's order for this procedure. Report complications promptly to the supervisor and the Attending Physician.An undated medical diagnoses list showed Resident #1 had diagnoses which included esophagitis, dysphagia, and traumatic hemorrhage of cerebrum.An untitled document showed RN #1 completed their training on tube feeding on 07/10/25.Resident #1's treatment administration record, dated 10/01/25 to 10/31/25, showed Resident #1 had an order for Osomolite 1.5 cal oral liquid (nutritional supplement), give 237 ml via peg tube every four hours. RN #1 initialed the 8:00 a.m. dose as being provided as ordered.A physician'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-12-02 · 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 record review and interview, the facility failed to ensure an RN was competent and possessed the necessary skills to provide care for 1 (#1) of 1 resident sampled for peg tubes.The DON identified one resident with a peg tube. Findings:A facility policy titled Enteral Tube Feeding via Syringe (Bolus), dated November 2018, read in part, Verify that there is a physician's order for this procedure.An undated medical diagnoses list showed Resident #1 had diagnoses which included esophagitis, dysphagia, and traumatic hemorrhage of cerebrum.An untitled document showed RN #1 completed their training on tube feeding on 07/10/25.Resident #1's treatment administration record, dated 10/01/25 to 10/31/25, showed Resident #1 had an order for Osomolite 1.5 cal oral liquid (nutritional supplement), give 237 ml via peg tube every four hours. RN #1 initialed the 8:00 a.m. dose as being provided as ordered.A physician's order, dated 10/10/25, showed Osmolite (enteral nutrition) 1.5 Cal oral liquid, give 237 ml via peg tube every four hours for nutrient, flush peg tube with 60 ml of water…

    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
  • Actual harm · Gcited before2025-10-02 · 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 record review and interview, the facility failed to ensure fall interventions were initiated to prevent reoccurring falls for 1 (#10) of 2 sampled residents reviewed for falls.The administrator identified 74 residents resided in the facility. Findings: A review of March 2025 incidents showed Resident #10 had a non-injury fall on 03/07/25 and 03/17/25.Resident #10's fall risk assessment, dated 03/17/25, showed the resident had moderate risk for falls with a score of 9.An incident report, dated 03/19/25 at 9:00 p.m., read in part, Notified by staff that resident had a fall. Nursing assessment completed and observed with 5cmx5cm scalp hematoma. Neurological checks initiated and resident was assisted to bed. Resident states [gender withheld] was trying to close the curtain and lost [gender withheld] balance.Resident #10's fall risk assessment, dated 03/19/25, showed the resident had moderate risk for falls with a score of 13.There were no documented interventions to prevent falls or injuries related to the fall on 03/19/25.Resident #10's annual 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-10-02 · tag F0574 — widespread
    The resident has the right to receive notices in a format and a language he or she understands.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure contact information for filing a complaint with the State agency was available to the residents.The administrator identified 74 residents resided in the facility. Findings:On 09/26/25 at 4:08 p.m., the administrator and surveyor observed the information board. On 09/26/25 at 2:38 p.m., the resident council group stated the contact information for filing a complaint with the State agency was covered and not visible. They stated they wanted to contact the State agency a month ago, but could not. On 09/26/25 at 4:06 p.m., the administrator stated the information for filing a complaint with the State agency was posted at the information board by the facility entrance. On 09/26/25 at 4:08 p.m., the administrator stated the contact information on the form was not visible to residents.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-10-02 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure the most recent state survey results were readily accessible to residents, family members, and legal representatives of the residents.The administrator identified 74 residents resided in the facility. Findings: On 09/26/25 at 1:39 p.m., the information board observed at the facility entrance showed the current survey and past three years of state survey were available at the screening desk.The surveyor was unable to locate the past survey results at the screening desk.On 09/26/25 at 2:34 p.m., the resident council group stated the past survey results were located at the nurses' station.On 09/26/25 at 4:13 p.m., the administrator provided the past survey results binder from inside the nurses station. They stated residents were not allowed to enter the nurses station. The administrator stated the results should be on the nurses station counter for resident access.On 09/26/25 at 4:23 p.m., the administrator stated the binder did not contain results of the 2024 annual recertification survey.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-10-02 · 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 record review and interview, the facility failed to ensure residents and their representatives were invited to care plan meetings for 2 (#4 and #31) of 18 sampled residents whose care plans were reviewed.The administrator identified 74 residents resided in the facility. Findings:A Care Plans, Comprehensive Person-Centered policy, revised 03/2022, read in part, The resident is informed of his or her right to participate in his or her treatment, and provided advanced notice of care planning conferences .If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.1. On 09/26/25 at 3:24 p.m., the resident council group stated the facility did not invite residents or their representatives to care plan meetings.2. Resident #31's annual resident assessment, dated 08/28/25, showed the resident's cognition was intact with a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-02 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure insulin was administered per physician's orders for 1 (#6) of 5 sampled residents reviewed for unnecessary medications.The administrator identified 74 residents resided in the facility.Findings: An Insulin Administration policy, revised 2014, read in part, To provide guidelines for the safe administration of insulin to residents with diabetes.Document the resident's blood glucose before intervention.Note blood sugar after each administration An undated Diagnosis Report, showed Resident #6 had diagnosis which included type II diabetes mellitus.Physician orders, dated 01/23/25, showed to administer insulin glargine 69 units one time a day and insulin glargine 72 units one time a day.An August 2025 MAR showed missed doses for:a. insulin glargine 69 units on 08/09/25, 08/10/25, and 08/13/25 andb. insulin glargine 72 units on 08/19/25.A September 2025 MAR showed missed doses for: a. insulin glargine 69 units on 09/02/25 and 09/05/25 andb. insulin glargine 72 units on 09/20/25.On 10/02/25 at 11:41 a.m., LPN #4 stated if…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-02 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to follow the menu for mechanical soft portion size for 1 of 1 meal service observed.A Diet Type Report, dated 09/29/25, showed six residents received a mechanical soft diet. Findings:On 09/29/25 at 11:54 a.m., a #16 scoop (equivalent to 2 ounces) was observed on the grounded mechanical soft chicken pan.On 09/29/25 at 12:04 p.m., one #16 scoop of grounded chicken was put on a resident's plate.On 09/29/25 at 12:06 p.m., one #16 scoop of grounded chicken was put on a resident's plate.The PREPARATION OF FOODS policy, dated 07/2020, read in part, measured utensils are used to serve proportions as described on the menu.A 2025 Week 3 Day 16 menu showed to use a #8 scoop (equivalent to 4 ounces) to serve the grounded crunchy chicken ranch.On 09/26/25 at 3:26 p.m., a resident council group stated the meal portion sizes were either too large or too small.On 09/29/25 at 12:16 p.m., cook #1 stated they reviewed the serving sizes in the extended menu book prior to meal services.On 09/29/25 at 12:18 p.m., cook #1 stated they…

    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 · D2025-10-02 · 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, record review, and interview, the facility failed to ensure EBP and appropriate use of gloves was followed during catheter and perineal care for 1 (#7) of 1 sampled resident reviewed for urinary catheter use.The administrator identified 74 residents resided in the facility. Findings: On 10/01/25 at 3:51 p.m., EBP sign was observed by Resident #7's door and had instructions to wear a gown and gloves. Personal protective equipment supplies were in a storage drawer by the door. The supplies included gowns. On 10/01/25 at 3:53 p.m., CNA #1 was observed to don gloves, told the Resident #7 they would be performing catheter care, and adjusted the resident's bed.On 10/01/25 at 3:55 p.m., CNA #1 was observed to don new gloves and clean Resident #7's catheter. CNA #1 proceeded to clean the resident's groin.On 10/01/25 at 4:01 p.m., CNA #1 was observed to wash their hands, don new gloves, and retrieve a new brief and pad. CNA #1 rolled Resident #7 to their left side.On 10/01/25 at 4:04 p.m., CNA #1 was observed to clean Resident #7's anal area. There was a fecal smear on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to maintain a safe and homelike environment for the residents for 1 of 3 common areas observed. The administrator identified 78 residents resided in the facility. Findings:On 08/13/25 at 1:00 p.m., the following observations were made at the North end of hall one in the common area where residents participated in therapy, access to vending machines, and puzzle activities:a. a puzzle with a lamp was in progress on a table;b. two bags of dry sack concrete were stored on the floor blocking the pathway to the puzzle creating a trip hazard;c. a hospital bed with no sheets was stored and obscured the pathway to the resident puzzle activity;d. a broken recliner was stored and obscured the path to the resident puzzle;e. a wheelchair with an empty bucket and a bed grab bar around 4 feet in length was balanced across the arms of the wheelchair that was obscuring the path to the resident puzzle activity;f. a walking cane with 4 legs unattended in the pathway to the puzzle activity; andg. a red walker unattended in 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 · E2024-12-09 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview it was determined the facilty ensured residents were free of abuse for two (#1 and #3) of three residents reviewed for abuse. The administrator identified 70 residents resided in the facility. Findings: The facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, read in part, .Residents have the right to be free from abuse. neglect, misappropriation of resident property and exploitation. This includes but is not limited to .verbal, mental, sexual or physical abuse . Resident #1 interview questions forms, dated 11/27/24, read in part, .Question 1 have you been abused .by any staff working at the facility .[Certified Nurse Aide #5] said I couldn't keep my urinal because my arm was weak and I spilled it on my bed. He said I would have to go to the bathroom in the bed because I couldn't get up to go to the bathroom . an undated handwritten note, by the social service director, attached to Resident #1 interview questions form, read in part, [Resident #1] stated that [CNA #5] and a black aid who worked…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-14 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident's property was not misappropriated for one (#4) of four sampled residents reviewed for misappropriation. The administrator identified 76 residents resided in the facility. Findings: The facility Abuse and Neglect policy, revised 08/12/22, documented the facility would investigate all allegations of abuse, neglect, or misappropriation and analyze all occurrences of abuse during the next scheduled QA committee meeting. Res #4 had diagnoses which included MS. A quarterly MDS, dated [DATE], documented Res #4 was cognitively intact. A facility incident report, dated 09/13/24, documented Res #4's purse containing their wallet had been stolen from their safe while they were in the shower. An In-Service Training Report, dated 09/16/24 at 2:00 p.m., documented the facility provided training to staff over the facility abuse, neglect, and misappropriation policy. A final incident report, dated 09/19/24, documented the facility's…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2024-05-09 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 meals were served in a timely manner and frequency for four meal services and, for one of one Resident #3. The [NAME] identified 67 residents resided in the facility. Findings: A undated Meal times documented, read in part .Breakfast 07:00-09:00 .Lunch 11:30-1:30p.m Dinner 5:00p.m.-7:00p.m . A Meal Times and Frequency policy, dated 02/27/21, read in part .1. in nursing facilities, there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day However, the individuals in the group must agree to this meal span and a nourishing snack must be served . a. Resident meals were not served in the 14 hour window. b. Resident #3 meal was not served according to posted meal times. On 05/05/24 at 9:30a.m., the cook stated we are working short staffed in the kitchen and meals are late. On 05/05/24 at 9:32a.m., a breakfast tray was served in the dining hall. On 05/05/24 at 1:41p.m., a lunch tray was served in the dining hall. On 05/05/24 at 1:27p.m., a lunch tray 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · E2024-05-09 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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 provide residents a binding arbitration agreement that informed the resident or their representative of their right not to sign the agreement as a condition of admission or continued care. The DON identified 67 residents resided in the facility and all residents had signed a binding arbitration agreement. Findings: 1. Resident #11 was admitted on [DATE]. A review of Resident #11's medical record documented a copy of a binding arbitration agreement signed by the Resident on 07/13/18. The agreement did not document the resident could be admitted to the facility without entering into the arbitration agreement. 2. Resident #51 was admitted on [DATE]. A review of Resident #51's medical record documented a copy of a binding arbitration agreement signed by the Resident on 03/31/22. The agreement did not document the resident could be admitted to the facility without entering into the arbitration agreement. 3. Resident #23 was admitted on [DATE]. A review 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · 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 (#17 and #51) of 17 sampled residents reviewed for resident assessments. The Administrator identified 67 residents resided in the facility. Findings: 1. Resident #17 had diagnoses which included open left ankle wound and cerebral palsy. An Annual RAI assessment, dated 04/05/24, documented that Resident #17 had no pressure ulcers on question M0100A, there was a stage 3 present on question M0300C1. On 05/07/24 at 9:35 a.m., the MDS Coordinator stated question M0100A was answered incorrectly. 2. Resident #51 had diagnoses which included Rheumatoid Arthritis A Quarterly RAI assessment, dated 04/26/24, documented that Resident #51 had a stage 3 pressure ulcer that was present on admission and a stage 4 pressure ulcer. A Pressure Ulcer Skin Conditions form, dated 03/11/24, documented that Resident #51 had a sacral pressure wound that measured 1.21cm by 1.0cm by 0.1cm. That form did not document any staging. A Nurses admission Assessment, dated 03/13/24, documented that…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-09 · 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: a. adequate supervision was provided to prevent a fall for one (#7); and b. proper transferring techniques were used for one (#51) of three sampled residents reviewed for accident hazards. The Administrator identified 67 residents resided in the facility. 43 residents were dependent on staff for transfers. Findings: 1. Resident #7 had diagnosis which included Parkinson's Disease. A Falls and Fall Risk, Managing policy, revised March 2018, read in part, .5. If falling recurs after despite initial interventions, staff will implement additional or different intervention, or indicate why the current approach remains relevant . A Minimum Data Set, dated, 03/25/24, documented Resident # 7 Functional Assessment indicates they are a dependent resident for activities of daily living of which includes eating and transfers. On 05/05/24 at 1:27 p.m., Resident #7 was standing independently up from wheelchair and the wheel chair rolled back as resident attempted to sit back down. On 05/09/24 at 10:32 a.m., the DON…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a physician's order was in place for the use of a catheter for one (#51) of one sampled resident reviewed for catheter use. The DON identified that 13 residents had catheters in the facility. Findings: Resident #51 On 05/05/24 at 10:17 a.m., Resident #51 was observed to have a catheter. On 05/07/24 at 11:06 a.m., the Order Summary Report was reviewed for Resident #51, it had no physican order for a catheter. On 05/07/24 at 11:29 a.m., the DON stated that nurses are responsible for putting in physician orders. They stated we double check orders and note them, and put them into medical records. The DON stated they did not see an order for a catheter. On 05/08/24 at 3:51 p.m., the CNO stated the policy for using catheters was to have an appropriate diagnosis, have a physician's order and put it in the system before providing the cath care. The order should include the size and when to change the catheter.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 store and label food items according with professional standards for food safety. The DON identified 67 residents resided in the facility. Findings: A undated Food Storage policy, read in part .All foods should be covered, labeled, and dated and routinely monitored to assure that foods(including leftovers) will be consumed by their safe use of dates, or frozen (where applicable), or discarded . On 05/07/24 at 11:06a.m., food items where found in the freezer undated and unlabeled. On 05/07/24 at 11:07a.m., LPN #1 identifed the unlabeled and undated the food items as rolls, biscuits and chicken patties. On 05/07/24 at 11:08a.m., the LPN #1 stated the rolls, biscuits and chicken patties should be dated and labeled. FACILITY Kitchen

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to document the required information regarding a transfer in a resident's medical record for one (#218) of one sampled resident reviewed for hospitalization. The Administrator identified 67 residents resided in the facility. Findings: A Transfer Form policy, dated 03/17, read in part, .Should it become necessary to transfer a resident from the facility, a transfer form will be executed and forwarded with the resident .The transfer form .will include .advanced directive information, all special instructions or precautions for ongoing care .any other documentation .to ensure a safe and effective transition of care . A Do Not Resuscitate Order policy, dated 03/21, read in part, .Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital . Resident #218 had diagnoses which included heart failure and COPD. A physician order, dated 06/19/23, documented DNR. A nursing note, dated 04/24/24 at 2:06 p.m., documented Resident #218 was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-07 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure food was served at a palatable temperature for one of one meal observed for palatable temperature. The DON identified 63 residents who received their meals from the kitchen. Findings: The facility's undated,Serving In-Room Meals policy, read in parts, .The purpose of this procedure is to provide adequate nutrition for the resident .Check that hot foods are hot (but not too hot) and cold foods are cold . The facility's undated Food Temperatures policy, read in parts, .All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 [degrees] F .Hot food items may not fall below 135 [degrees] F after cooking .All cold food items must be stored at a temperature of 41 [degrees] F or below . On 11/03/23 at 12:06 p.m., a food cart was delivered to Hall 3. The dietary manager was asked to provide a test tray. The tray was placed on the hall food cart. On 11/03/23 at 12:09 p.m., CNA #1 began passing the hall trays. On 11/03/23 at 12:36 p.m., CNA #1 stated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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's overbed light was accessible for one (#4) of one sampled resident who was observed for accommodation of needs. The DON identified 63 residents who resided in the facility. Findings: Resident #4 had diagnoses which included multiple sclerosis. A quarterly assessment, dated 08/30/23, documented Resident #4's cognition was intact; required extensive assistance of one staff member for bed mobility, dressing, and personal hygiene; had impairment of upper extremities on one side and impairment to bilateral lower extremities; and utilized a wheelchair for ambulation. A grievance report, dated 09/28/23, documented Resident #4's light above their bed was broken and had to be replaced, and the resident did not like the light that was installed due to not being able to turn the light on and off when they wanted. The report documented the social service director offered to speak to the maintenance man concerning looking for a new light. The report documented Resident #4 had already spoken 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-07 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the physician of a change in condition for one (#1) of three sampled residents reviewed for changes in condition. The DON identified 63 residents who resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses which included chorea (sudden unintended and uncontrollable jerky movements), anemia, Vitamin B deficiency, hypomagnesemia, and DM. A History and Physical report form physician #1, dated 10/05/23, read in parts, .All acute problems as noted by the patient or nursing staff have been addressed at this time .Continue current orders as indicated in patient chart, as well as any orders outlined above. Contact provider with any changes or concerns . A nurse's progress note, dated 10/22/23 at 5:42 p.m., read in part, .Resident .appeared to have been asleep in his bed since approximately [2:00 p.m.]. Resident will not wake when aroused. Resident's son here and the son also can not get resident to wake up so…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to maintain a homelike environment free from urine odors for one of four halls observed. The DON identified 63 residents who resided in the facility. Findings: On 11/02/23 at 12:30 p.m., Hall 4 had a urine odor. On 11/03/23 at 11:00 a.m., upon entrance to the facility, Hall 4 had a strong urine odor. Staff in the administrator's office stated the smell was coming from the dirty utility room. On 11/06/23 at 1:30 p.m., Hall 4 had a strong urine odor. On 11/06/23 at 1:34 p.m., Hall 4 near room [ROOM NUMBER] had a strong urine odor. On 11/06/23 at 1:35 p.m., CNA #2 stated room [ROOM NUMBER] always smelled like urine. On 11/06/23 at 3:26 p.m., Hall 4 had a strong urine odor. On 11/07/23 at 8:49 a.m., Hall 4 had a strong urine odor near the MDS office and room [ROOM NUMBER]. CNA #2 stated they were working on trying to get rid of the urine odor. On 11/07/23 at 3:24 p.m., Resident #10 stated the CNA had told them the room had a bad odor. Resident #10 stated they…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-15 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    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 residents' call lights were within reach for three (#26, #42, and #58) of 24 residents reviewed for accommodation of needs. The Resident Census and Conditions of Residents documented 66 residents resided in the facility. Findings: 1. Res #58's care plan, dated 04/22/22, documented the resident had an ADL self care deficit related to hemiparesis and hemiplegia with an intervention to encourage the resident to use the call light to call for assistance. A quarterly assessment, dated 01/06/23, documented the resident was severely cognitively impaired, required extensive assistance with bed mobility, transfer, and most ADLs. The assessment documented the resident had impairment of the left upper extremity and left lower extremity. On 03/08/23 at 6:10 a.m., Res #58 was observed lying in bed with eyes open. The call light was observed attached to a hook on the wall just below the light fixture. The resident was asked if she was able to reach her call light. The resident stated the call light was too high 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-15 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to perform incontinence care in a timely manner for two (#36 and #66) of 24 residents reviewed for incontinence care. The Resident Census and Conditions of Residents form documented 49 residents required assistance with incontinence care. Findings: 1. Res #36 was admitted to the facility with diagnoses of Parkinson's disease, acute kidney failure, and polyneuropathy. A quarterly assessment, dated 12/17/23, documented the resident's cognition is moderately impaired and required extensive assist with the use of a lift for transfers. On 03/09/23 at 8:45 a.m., Res #36 was observed in the dining room with staff assisting him with breakfast. There was a puddle of liquid observed under his chair. On 03/09/23 at 8:49 a.m., the resident was observed being taken to his room by CNA #2. The CNA was asked if she was about to change him and she reported not yet, I have to have help. On 03/09/23 at 8:56 a.m., CNA #2 and CMA #3 were observed entering the resident's room to perform incontinent care. CNA #2 and CMA #3 used 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-15 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    3. Res #23's physician order, dated 07/28/21, documented skin checks weekly by licensed nurse on three to eleven shift. A quarterly assessment, dated 01/05/23, documented the resident required extensive assistance with ADLs and was at risk for pressure ulcers/injuries. A review of the resident's electronic chart contained no documentation of skin assessments. On 03/13/23 at 10:31 a.m., the DON reported skin assessments should be documented in the progress notes under assessments. On 03/13/23 11:31 a.m., LPN #2 reported skin assessments were documented in the computer. On 03/13/23 3:28 p.m., the DON was notified of no documentation of weekly skin assessments found in the resident's chart. She reported she would look and see if there was any on paper. The DON did not provide any documentation. Based on record review and interview, the facility failed to ensure: a. hospital emergency room departure instructions were followed for one (#47) of one sampled resident reviewed for change in condition, b. blood sugars were rechecked according to physician orders for one (#54) of seven sampled…

    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 · D2023-03-15 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 MDS assessments were coded accurately for hospice services for one (#22) of one sampled resident reviewed for hospice services. The Resident Census and Conditions of Residents report, dated 03/09/23, documented 26 residents were receiving hospice care. Findings: Res #22 had diagnoses which included CVA. A physician's order, dated 05/24/22, documented admitted to hospice. The order was discontinued on 08/20/22. An admission assessment, dated 05/25/22, documented the resident had a condition or chronic disease that could result in a life expectancy of less than six months. It was not documented the resident received hospice services while a resident A physician's order, dated 08/20/22, documented admitted to hospice. A quarterly assessment, dated 02/08/23, did not document the resident had a condition or chronic disease that could result in a life expectancy of less than six months. There was no documentation the resident received hospice services while a resident. On 03/14/23 at 2:57 p.m., MDS coordinator #1 was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to follow physician orders for wound care on one (#56) of two residents reviewed for wound care. The Residents Census and Conditions of Residents form documented five residents with wounds. Findings: Res #56 admitted to the facility on [DATE] with diagnoses of cord syndrome at unspecified level of cervical spinal cord, nondisplaced fracture of the first cervical vertebra, and acute pain due to trauma. An admission assessment, dated 02/27/23, documented the resident's cognition was moderately impaired and required extensive assist. A care plan, dated 03/03/23, documented the resident had a stage II pressure ulcer to left buttock and a stage I pressure ulcer to the sacrum. The care plan documented the resident's pressure ulcer would show signs of healing and remain free from infection by/through review date, treatments as ordered, wound care as ordered, and Braden Scale Assessments weekly for first 4 weeks then quarterly or more often as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-15 · 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 record review and interview, the facility failed to conduct an intervention of 72 hour monitoring after a resident had a fall for one (#22) of one sampled resident reviewed for accidents. The Resident Census and Conditions of Residents report, dated 03/09/23, documented 66 residents resided in the facility. Findings: Res #22 had diagnoses which included CVA. A health status note, dated 05/19/22 at 11:25 p.m., documented the nurse was called to the resident's room where they were found sitting on their buttocks on the floor. It was documented the resident's back was next to the bed and their legs were straight out in front of them. It was documented an assessment was conducted and no injuries were found. It was documented the resident was placed on 72 hour monitoring. There was no documentation 72 hour monitoring was conducted. On 03/14/23 at 3:30 p.m., corporate nurse consultant #1 was asked to locate the 72 hour monitoring conducted for the fall the resident had in May 2022. On 03/14/23 at 3:56 p.m., the DON stated there was no 72 hour monitoring conducted for 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-15 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure pain medications were available as ordered by the physician for one (#59) of seven sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 03/09/23, documented 41 residents were on a pain management program. Findings: Res #59 had diagnoses which included pain. A quarterly assessment, dated 12/28/22, documented the residents' cognition was intact. It documented the resident had pain almost constantly. A physician's order, dated 06/20/22, documented acetaminophen (pain reliever/fever reducer) 325 mg two tablets every four hours as needed for pain. A physician's order, dated 09/29/22, documented hydrocodone-acetaminophen (pain medication) 10-325 mg every fours hours as needed for pain. The March 2023 MAR, documented on 03/08/23 at 7:29 a.m. acetaminophen was administered when the resident's pain level was rated as a 9. The medication was documented as ineffective. On 03/08/23 at 11:45 a.m., Res #59 was observed in their bed with the lights off. They were…

    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 · D2023-03-15 · 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 ensure PRN orders for psychotropic drugs were limited to 14 days for one (#47) of seven sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 03/09/23, documented 28 residents received psychoactive medications. Findings: Res #47 had diagnoses which included anxiety. A physician order, dated 01/26/23, documented lorazepam (benozodiazepine) 0.5 mg every eight hours as needed. The order was discontinued on 02/16/23. There was no rationale for the order to be extended beyond 14 days. The January and February 2023 MARs were reviewed. It was documented lorazepam was administered three times beyond 14 days. On 03/13/23 at 2:47 p.m., corporate nurse consultant #1 was asked what was the protocol for administering PRN psychotropic medications. She stated 14 days, then the order should be renewed. She was made aware of the Res #47's order. She was asked to provide documentation of the rationale from the physician to extend the order beyond 14 days. On 03/13/23 at 3:23 p.m., the DON…

    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 · D2023-03-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, it was determined the facility failed to ensure the removal of expired medication from the medication storage room. The Resident Census and Conditions of Residents report documented 66 residents resided in the facility. Findings: On 03/14/23 at 3:16 p.m., a tour of the medication room was conducted. The following expired medications were observed: a. 1 albuterol sulfate inhaler with a use by date of 03/08/23. b. 2 acetaminophen suppositories 650mg with an expiration date of 03/02/23. c. 1 vial of Tuberculin Purified Protein, dated 01/02/23. d. 1 vial of Tuberculin Purified Protein, dated 01/07/23. On 03/14/23 at 3:35 p.m., the DON was asked if the above medications should have already been removed from the medication room. The DON stated, Yes.

    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

$23,179 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $9,110 — penalty dated 2025-12-02
  • $14,069 — penalty dated 2025-10-02
  • Medicare payment denial — starting 2025-11-11 for 10 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 IHS MANAGEMENT CONSULTANTS — 5 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 →

RatingThis homeChain avg
Overall 1 of 52.6-1.6 vs chain
Health inspection 1 of 52.6-1.6 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 2 of 52.2-0.2 vs chain
The other 4 homes this chain runs (chain average 2.6★, 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 / managerTypeRoleShareSince
BK STRATEGIES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2021
REED, BARTIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL100%since 01/01/2021
SORUM, JASONIndividualW-2 MANAGING EMPLOYEEsince 01/01/2021

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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.2M
Net patient revenuemost recent cost report
+1.9%
Operating marginrevenue minus expenses
$912K
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 79%Medicare 1%Other / private 20%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $912K 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 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

$221per resident / day
operating cost
$6,732per month
≈ monthly operating cost
$226per 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 375222. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-02, 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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