Capitol Hill Skilled Nursing And Therapy
2400 Southwest 55th Street, Oklahoma City, OK 73119 · For profit - Individual · 120 certified beds · (405) 681-5381 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.0% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.8% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.7% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 3.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.4% | 4.7% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.9% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.7% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.0% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.7% | 17.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.9% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 66.7% | 74.1% | 79.4% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.7% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.7%CMS range 36.0–60.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.6–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | 97.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.5–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 70.9 residents a day — about 59% occupied, or roughly 49 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.483 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.14 hrs/resident/day on weekends vs 3.62 on weekdays — 13% thinner on weekends. RN hours go from 0.20 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · F2026-06-19 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure the 2 (Dumpster #1 and Dumpster #2) of 3 dumpsters in the facility were kept covered at all times. This deficient practice had the potential to affect all residents who currently reside in the facility.Findings included: An undated facility policy titled, Safe Facilities and Pest Management, specified, Make sure the containers have tight-fitting lids and are kept covered at all times. During an observation of the facility garbage receptable area on 06/15/2026 at 9:02 AM, the surveyor noted there were three dumpsters and Dumpster #1 had no side door to close the dumpster and there was opened access to the trash located in the dumpster. The surveyor noted Dumpster #2 did not have a functioning lid, it was left opened and there were flying insects in and around both Dumpster #1 and Dumpster #2. During an observation of the facility garbage receptable area on 06/16/2026 at 12:49 PM with the Dietary Supervisor (DS) and the Regional Dietary Consultant (RDC), the surveyor noted Dumpster #2 had no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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, interview, and document review, the facility failed to accommodate the needs for 1 (Resident #30) of 1 sampled resident who required a specialized call light. Findings included: On 06/16/2026 at 10:30 AM, the Administrator stated the facility did not have a policy regarding accommodation of residents' needs. A document titled, AliMed Worry-Free Pull-Cord Alarm, #72140 Instructions for Use and Care, indicated, A tug on the cord in any direction will cause magnetic sensor to release and alarm will be triggered. An admission Record revealed the facility admitted Resident #30 on 10/19/2025. According to the admission Record, the resident had a medical history that included diagnoses of dementia and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2026, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-19 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure as-needed antipsychotic medication was limited to 14 days for 1 (Resident #59) of 5 sampled residents reviewed for unnecessary medications.Findings included: A facility policy titled, Appendix 19: Medications Requiring Behavior & Side Effect Monitoring, updated 10/25/2021, specified, PRN [pro re nata, as needed] anxiolytics can have only an initial 14 day stop date. They can be continued for longer periods of time such as 30 [days], 60 [days], or 90 [days] days as long as the prescribing physician indicates that new stop date - they cannot be continued indefinitely. Per the Appendix 19: Medications Requiring Behavior & Side Effect Monitoring, Xanax was listed as an anxiolytic medication. An admission Record indicated the facility admitted Resident #59 on 01/04/2023. According to the admission Record, the resident had a medical history that included a diagnosis of anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2026, revealed Resident #59…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-19 · tag F0609 — failed to report abuse allegations — isolatedTimely 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, record review, document review, and facility policy review, the facility failed to ensure an allegation of abuse was timely reported to the state survey agency for 1 (Resident #72) of 1 sampled resident reviewed for abuse.Findings included: A facility policy titled, Reports to State and Federal Agencies, revised 02/02/2018, revealed, Timeline for Reporting. All reports to the Department shall be made by telephone or facsimile. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries on unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. An admission Record revealed the facility admitted Resident #72 on 11/06/2025. According to the admission Record, the resident had a medical history that included a diagnosis of malignant neoplasm of bone. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2025,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-19 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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, and document review, the facility failed to educate the staff on the proper usage of a pull-cord alarm for 1 (Resident #30) of 1 sampled resident who required a specialized call light. Findings included: On 06/16/2026 at 10:30 AM, the Administrator stated the facility did not have a policy regarding accommodation of residents' needs. A document titled, AliMed Worry-Free Pull-Cord Alarm, #72140 Instructions for Use and Care, indicated, A tug on the cord in any direction will cause magnetic sensor to release and alarm will be triggered. An admission Record revealed the facility admitted Resident #30 on 10/19/2025. According to the admission Record, the resident had a medical history that included diagnoses of dementia and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2026, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure 1 (200 Hall medication cart) of 5 medication carts in the facility was kept locked when out of sight of the staff authorized to have access. Findings included: A facility policy titled, Medication Storage in the Facility, effective 01/2022, indicated, Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is assessable only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy specified, Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. During a concurrent interview and medication administration observation on 06/16/2026 at 7:52 AM, Certified Medication Aide (CMA) #12, being trained by Licensed Practical Nurse (LPN) #8, was observed to leave the medication cart on the 200 Hall unlocked while she administered a resident's medications in the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 call light was within reach of a resident for one (#20) of 24 sampled residents observed for call lights in reach. The administrator identified 65 residents resided in the facility. Findings: Resident #20 had diagnoses which included chronic respiratory failure with hypercapnia. Resident #20's quarterly resident assessment, dated 09/27/24, documented the resident had moderate cognitive impairment. Resident #20's care plan for falls, revised 10/17/24, documented call light in reach and encourage to use. On 11/06/24 at 10:41 a.m., Resident #20 called out to the surveyor and asked the surveyor to hand them their call light. The call light was on the recliner and out of the reach of the resident. Resident #20 was sitting in a wheelchair. The resident was asked how they would call for help with the call light out of their reach. Resident #20 stated, They cant. The resident stated they needed ice water. On 11/06/24 at 10:54 a.m., CNA #4 stated the policy was to ensure the call light was always in reach.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident's ceiling vent was cleaned for one (#55) of three sampled residents reviewed for a clean, comfortable, and homelike environment. The administrator identified 65 residents resided in the facility. Findings: The Housekeeping Policies and Procedures policy, revised 06/29/12, read in part, Weekly Procedures: Begin cleaning resident rooms from the ceiling and work toward the floor. The only part of the room which is allowed to be dry dusted is the ceiling, high vents, and other high dust areas. Resident #55's quarterly resident assessment, dated 10/18/24, documented Resident #55 was cognitively intact. On 11/06/24 at 8:56 a.m., Resident #55's ceiling vent was observed to have moderate dust build up. On 11/08/24 at 12:04 p.m., Resident #55's ceiling vent was observed to have moderate dust build up. Resident #55 stated they had not cleaned the vent. On 11/08/24 at 12:59 p.m., Housekeeper #1 stated they had not paid attention to the ceiling vents in the resident rooms during their cleaning…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a MDS was coded accurately for one (#42) of 17 sampled residents reviewed for MDS assessments. The administrator identified 65 residents resided in the facility. They identified one resident received dialysis. Findings: Resident #42 had diagnoses which included end stage renal disease. A Care Plan, dated 07/11/24, documented the resident received dialysis at a local facility three times a week. A Quarterly Assessment, dated 10/01/24, did not code Resident #42 received dialysis. On 11/07/24 at 11:01 a.m., MDS Coordinator #1 stated if someone was receiving dialysis then it would be coded on the MDS. They reviewed Resident #42's MDS and stated it was not coded. They stated it was not accurate.
- Potential for harm · D2024-11-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 hold a care plan meeting for one (#35) of one sampled resident reviewed for a care plan meeting. The administrator identified 65 residents resided in the facility. Findings: Resident #35 had diagnoses which included unspecified dementia and need for assistance with personal care. On 11/07/24 at 1:19 p.m., Resident Rep #1 stated a care plan meeting was scheduled for 10/24/24. They stated the facility did not inform them the reason the care plan meeting was not held and if it would be rescheduled. On 11/08/24 at 8:01 a.m., the administrator stated the social worker was responsible for care plan meetings. They stated the current social worker had been in their position for a week. The administrator stated care plan meetings were held quarterly. On 11/08/24 at 8:06 a.m., the administrator stated the last care plan meeting held for Resident #35 was on 07/25/24. They stated another meeting was scheduled for 10/24/24. On 11/08/24 at 8:08 a.m., the administrator stated the care plan meeting was not held because the social worker…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 9 citations
- Potential for harm · Dcited before2024-11-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — 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 expired medication was removed from circulation in one of one medication storage rooms. The administrator identified 65 residents resided in the facility. Findings: A Medication Storage in the Facility policy, dated 01/22, read in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Outdated .medications .are immediately removed from inventory, disposed of according to procedures for medication disposal Resident #12 had diagnoses which included other recurrent depressive disorders. A Physician Order, dated [DATE], documented sertraline (Zoloft an antidepressant medication) 100 mg give one tablet by mouth one time a day related to other recurrent depressive disorders. On [DATE] at 7:07 a.m., the medication storage room was observed with the DON present. The DON stated staff printed off an order, faxed it to the pharmacy, and called the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a urinalysis specimen was obtained in a timely manner for one (#35) of six sampled residents reviewed for laboratory services. The administrator identified 65 residents resided in the facility. Findings: Resident #35 had diagnoses which included unspecified dementia and UTI. A Physician's Telephone Order, dated 10/15/24, documented CBC, CMP, PCR UA, TSH, and Depakote level for generalized weakness. A Lab Report, dated 10/16/24, documented a urine specimen was collected. On 11/08/24 at 9:27 a.m., LPN #4 stated nurses were responsible for obtaining urine specimens. On 11/08/24 at 9:28 a.m., LPN #4 stated they spoke with the resident's family member on 10/25/24. The resident's family member had inquired about the status of the urinalysis. They stated the urine specimen that was collected was not sent to the lab. LPN #4 stated the urine specimen was still in the ice box. They stated they called the provider to verify it was ok to obtain another urine specimen. LPN #4 stated a new urine specimen was collected on 10/25/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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: a. report an abnormal urinalysis result to the provider in a timely manner for one (#35) of six sampled residents reviewed for laboratory services; and b. develop a lab policy. The administrator identified 65 residents resided in the facility. Findings: Resident #35 had diagnoses which included unspecified dementia and UTI. A Physician's Telephone Order, dated 10/15/24, documented CBC, CMP, PCR UA, TSH, and Depakote level for generalized weakness. A Lab Report, documented a urine specimen was collected on 10/26/24 and reported on 10/29/24. It documented Resident #35 was positive for a UTI. A Physician Order, dated 11/05/24, documented Cipro (an antibiotic) 500 mg give one tablet by mouth two times a day for UTI for seven days. There was no documentation the provider was notified of the abnormal urinalysis result on 10/29/24. On 11/08/24 at 9:32 a.m., LPN #4 reviewed Resident #35's urinalysis result. They stated the results were reported to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow up on a physician ordered dental referral for one (#60) of three sampled residents reviewed for dental care. The administrator identified 65 residents resided in the facility. Findings: A Dentures and Related Services policy, dated 06/27/17, documented when the provision of denture services were medically appropriate, the facility must make timely arrangements. Resident #60 had diagnoses which included chronic obstructive pulmonary disease. An admission Note, dated 06/13/24 at 3:22 p.m., documented Resident #60 wore upper dentures and had their own teeth on the bottom. A physician's order, dated 09/24/24, documented to refer Resident #60 to a dentist for a new upper denture plate. A Quarterly Assessment, dated 09/26/24, documented Resident #60's cognition was intact. It documented the resident had broken or loosely fitting full or partial denture. On 11/06/24 at 9:26 a.m., Resident #60 stated they had lost their dentures about a month ago. They stated they had told their physician and they had wrote an order, but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to adhere to enhanced barrier precautions for one (#26) of one sampled resident reviewed for enhanced barrier precautions. The administrator identified 65 residents resided in the facility and 19 residents were on enhanced barrier precautions. Findings: The Enhanced Barrier Precautions policy, revised 03/28/24, read in part, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier precautions include: Device care or use .feeding tube. Resident #26 had diagnoses which included cachexia and severe protein-calorie malnutrition. Resident #26's care plan for EBP, revised 09/24/24, documented the resident was at risk for infection related to peg tube and secondary to in-house MDRO. It documented to maintain enhanced barrier precautions. On 11/06/24 at 2:29 p.m., LPN #2 was observed entering Resident #26's room. There was an EBP sign on the door for bed A. There were gowns hung on a yellow storage container on the bathroom door. On 11/06/24 at 2:30 p.m., LPN #2 with gloves on,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0914 — isolatedProvide bedrooms that don't allow residents to see each other when privacy is needed.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident had a privacy curtain for one (#55) of 24 sampled resident rooms reviewed for privacy. The administrator identified 65 residents resided in the facility. Findings: Resident #55 had diagnoses which included diabetes mellitus type two. A Quarterly Assessment, dated 10/18/24, documented Resident #55's cognition was intact. On 11/06/24 at 8:52 a.m., Resident #55 was observed sitting on their bed in their room. There was not a privacy curtain available to pull across the room to provide complete privacy. Resident #55 stated they would have liked to have one for privacy. On 11/12/24 at 8:26 a.m., LPN #1 stated the curtains were to be closed to provide privacy to the residents. LPN #1 was asked to look at Resident #55's room. They were asked if the resident had curtains to provide privacy. They stated, If [they] want one. Resident #55 stated, Yes, I want one for privacy.
- Potential for harm · Dcited before2023-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, record review, and interview, the facility failed to ensure the sink located in the resident's room was operational for one (room [ROOM NUMBER]) of 23 sampled resident rooms observed. The Resident Census and Conditions of Residents report, dated 08/24/23, documented 56 residents resided in the facility. Findings: The facility's Maintenance policy, dated 06/27/06, read in part, .The maintenance department will be given checklists to assure orientation to their responsibilities of preventative maintenance items, and assure the good repair of the entire facility .In the event that an item is in need of repair, the defect should be reported to the maintenance department on form MAINT-054, and the maintenance department will repair them promptly . On 08/24/23 at 9:42 a.m., Resident #14 stated the sink in resident room [ROOM NUMBER] had not worked in a month. Resident #14 stated the maintenance man turned off the water a month ago due to a leak. The sink was turned on and no water was observed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure an expired medication was not prepared for administration for one (#35) of three residents observed during medication administration. The Resident Census and Conditions of Residents report, dated 08/24/23, documented 56 residents resided in the facility. Findings: A Medication Storage in the Facility policy, dated January 2022, read in part, .Outdated .medications .are immediately removed from inventory, disposed of .Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified .The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining . Resident #35 admitted with diagnoses which included hypotension and history of traumatic brain injury. A physician order, dated 08/11/23, 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.
- Potential for harm · D2023-08-29 · tag F0772 — isolatedHave 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 obtain physician ordered labs for one (#14) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/24/23, documented 56 residents resided in the facility. Findings: Resident #14 had diagnoses which included type two diabetes mellitus, hypertension, chronic respiratory failure, and artherosclerotic heart disease of native coronary artery without angina pectoris. A Physician Progress Note, dated 06/04/23, read in part, .LAB .Order: A1c q6 Months .recheck BMP and Magnesium in 10 days . The progress note was electronically signed by Physician #1 on 06/06/23. There were no results for the above lab orders located in Resident #14's record. On 08/29/23 at 8:26 a.m., the Administrator was asked to provide the lab results for Resident #14's A1c, BMP, and magnesium lab order documented in Physician #1's 06/04/23 note. On 08/29/23 at 10:15 a.m., the DON stated the facility did not get a verbal or telephone order at the time Physician #1 wrote the order 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to BRIDGES HEALTH — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.6 | -0.6 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 4 of 5 | 3.0 | +1.0 vs chain |
The other 32 homes this chain runs (chain average 3.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BRIDGES EMPLOYEE STOCK OWNERSHIP TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 12/31/2020 |
| DEROIN, KRISTY | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2020 |
| COBLE, WILLIAM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2020 |
| BRIDGES ESOP, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/31/2020 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 81% 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 $585K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375151. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-19, 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.