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Heritage At Brandon Place Health & Rehabilitation

13500 Brandon Place, Oklahoma City, OK 73142 · For profit - Limited Liability company · 118 certified beds · (405) 720-0010 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Dec 20241 immediate-jeopardy citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$35,311 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Dec 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $35,311 in federal fines (most recent 2024-12-09)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (87%) runs well above the national median (45%)

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

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

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

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
13401 N MacArthur Blvd Ste 108 · (405) 755-2273 · Call to confirm hours
Pharmacy
5915 W Memorial Rd Ste 110 · (405) 773-2300 · Call to confirm hours
Grocery
12200 N MacArthur Blvd · (405) 384-7577 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
13112 N Rockwell Ave · (405) 721-2929

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 5 of 5
Long-stay residentspeople who live here 5 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 improved from 1 to 3 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 rating3★
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 increased11.8%13.6%15.4%better
Long-stay residents who lose too much weight3.6%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.9%1.9%0.9%typical
Long-stay residents with a urinary tract infection0.0%2.8%2.0%better
Long-stay residents with depressive symptoms6.0%3.4%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.9%4.7%3.3%worse
Long-stay residents whose ability to walk worsened14.7%13.7%16.1%typical
Long-stay residents on antianxiety or hypnotic medication15.8%25.7%18.9%better
Long-stay residents given the seasonal flu vaccine77.9%94.6%95.3%worse
Long-stay residents with pressure ulcers6.8%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control22.8%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table18.8%17.5%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine66.7%74.1%79.4%worse
Long-stay hospitalizations per 1,000 resident days0.642.311.67better
Long-stay outpatient ER visits per 1,000 resident days0.572.961.80better

§ 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.

0.13U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a 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 identified45.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in 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

0.21
RN hours/ resident / day
1.01
LPN hours/ resident / day
1.72
Aide hours/ resident / day
2.94
Total nurse hours/ resident / day
0.16
RN hoursweekends
87.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 118 beds and averages 49.1 residents a day — about 42% occupied, or roughly 69 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 2.94 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 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 2.67 hrs/resident/day on weekends vs 3.04 on weekdays — 12% thinner on weekends. RN hours go from 0.23 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 87% is well above the national median of 45%.

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

Inspection trend

2
deficiencies at the latest standard inspection (2026-01-14)
4
at the previous standard inspection (2024-05-31)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · J2024-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 08/16/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #2, who had a known history of unsafe smoking did not smoke in their room and catch themselves on fire. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia. Resident #2 was admitted to the hospital on [DATE] with second and third degree burns. On 08/16/24 at 11:45 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to for Res #2 smoking in their room and catching themselves on fire. On 08/16/24 at 11:47 a.m., the administrator was notified of the IJ situation. On 08/19/24 at 9:10 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Plan of Removal (Accident Hazards Related to Smoking Without Supervision) Tag Cited: F-689 (Accident Hazards Related to Smoking Without Supervision) Preparation and/or execution of this…

    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 · G2024-12-09 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident who experienced pain received treatment for pain for one (#2) of three sampled residents reviewed for pain management. The VP of clinical services identified 46 residents had orders for pain management in the facility. Findings: The Administering Pain Medications policy, revised 10/10, read in part, The pain management program is based on a facility-wide commitment to resident comfort. The policy also read, .Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained .Administer pain medication as ordered .document the following in the resident's medical record: results of the pain assessment; medication; dose; route of administration; and results of the medication. Resident #2 was admitted on [DATE] and had diagnoses which included pain, dementia, and displaced comminuted fracture of shaft of humerus, left arm, subsequent encounter for fracture with routine…

    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 · Past Non-Compliance
  • Potential for harm · E2026-05-07 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to follow enhanced barrier precautions and perform hand hygiene to prevent the development of infections for 1 (#1) of 3 sampled residents reviewed for infection control.The DON identified 55 residents resided in the facility and 13 residents with enhanced barrier precautions. Findings:On 05/05/26 at 12:40 p.m., CNA #1 and CNA #2 were observed providing incontinent care for Resident #1. A sign posted at Resident #1's door read, enhanced barrier precautions, staff must wear gown and gloves for bathing, changing linen, and providing hygiene for the resident. CNA #1 and CNA #2 did not wear a gown when providing care. CNA #1 did not wash or sanitize their hands when changing their gloves and moving from a dirty area to a clean area. On 05/05/26 at 2:25 p.m., LPN #1 was observed to change the wound vac dressing for Resident #1. LPN #1 was not wearing a gown. LPN #1 stated they did not know the resident was on enhanced barrier precautions. LPN #1 placed a new wound vac dressing, removed their gloves, and did not wash…

    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 · D2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide treatment and care for a resident with a wound vac for 1 (#1) of 1 sampled resident reviewed for a wound vac. The DON identified one resident with a wound vac. Findings:On 05/05/26 at 12:00 p.m., Resident #1 was observed lying in a bariatric bed with an air mattress in place watching television. Resident #1 had a wound vac to the abdomen, the dressing was not dated, and the wound vac machine was turned off.An undated admission record showed Resident #1 had diagnoses which included local infection of the skin and subcutaneous tissue, type 2 diabetes mellitus, pressure ulcer of contiguous site of back, buttock, and hip stage 2.An undated facility policy titled Negative Pressure Wound Therapy, read in part, Whenever therapy cannot be resumed within two hours, remove the dressing and apply a moist wound dressing. Notify physician for specific orders.A treatment administration record, dated 04/21/26, showed a treatment for a midline abdomen surgical wound. The order showed the staff was to cleanse 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 before2026-05-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide pressure ulcer treatments to promote healing and prevent infection for 1 (#1) of 3 sampled residents reviewed for pressure ulcers. The DON identified three residents with pressure ulcers. Findings:On 05/05/26 at 12:42 p.m., CNA #1 and CNA #2 were observed to enter Resident #1's room to provide incontinent care. CNA #2 positioned Resident #1 on their side and CNA #1 washed Resident #1's buttock. There was packing in the pressure ulcer, but no dressing covering the wound. Bowel was on the edges and inside edges of the pressure ulcer. When CNA #1 was rolling the soiled linen to discard CNA #1 also caught the packing that was in the pressure ulcer wound bed. CNA #1 removed the packing part of the dressing with the soiled linen. CNA #1 did not tell the nurse about the resident's dressing (packing) being removed.On 5/06/26 at 10:17 a.m., the ADON was observed to complete wound care to the bilateral gluteal folds for Resident #1. There was no dressing covering the pressure ulcer wounds. An undated admission…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-01-14 · 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 post notice of the availability of past State survey results in areas of the facility that were prominent and accessible to residents, representatives, and the public.The DON identified 48 residents resided in the facility. Findings:On 01/12/26 at 11:34 a.m., a tour of the facility was conducted. There was no notice informing the public where the past State survey results were posted.On 01/12/26 at 11:40 a.m., the past State survey results were observed in a binder on the administrator's door in a file holder.On 01/12/26 at 11:44 a.m., the administrator stated the there was no notice posted about where to locate the past State survey results. They stated it should have been posted on the bulletin board.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-14 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for 3 (#1, 3, and #7) of 4 sampled residents reviewed for assistance with ADLs.The DON identified 38 residents required assistance with bathing. Findings: An Activities of Daily Living (ADLs) policy, revised 01/26/25, read in part, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, and grooming .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. A facility Bath List schedule, dated 11/07/25, showed Resident #7 was to receive showers three times a week on Tuesday, Thursday, and Saturday. Resident #7's quarterly resident assessment, dated 11/14/25, showed the resident had moderate cognitive impairment with a BIMS of 12. The assessment showed Resident #7 required partial to moderate assistance from staff for showers. A facility…

    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 · E2024-12-09 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents' property was not misappropriated for three (#3, 4, and #7) of three sampled residents reviewed for misappropriation. The administrator identified 74 residents resided in the facility. Findings: An undated ABUSE, NEGLECT, EXPLOITATION AND MISAPPROPRIATION OF PROPERTY PROHIBITION policy, read in part, The Facility will ensure a safe environment for residents by prohibiting abuse, neglect, exploitation and misappropriation of resident property with mechanisms for reporting, investigating, and protecting residents from actual or potential harm. 1. Resident #7 had diagnoses which included hypertensive heart disease with heart failure. A nursing note, dated 08/03/24 at 1:50 p.m., documented the resident reported someone had moved their card in their wallet. They looked at their online banking and noticed that on 08/01/24 there were two withdrawals. One withdrawal was for $440 and one was for $500. An Initial State Reportable Incident form, dated 08/03/24, documented an allegation of misappropriation of resident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-09 · 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 call light was within reach of a resident for one (#1) of three sampled residents observed for call lights in reach. The administrator identified 74 residents resided in the facility. Findings: A Call Lights: Accessibility and Timely Response policy, dated 05/2024, read in part, The purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance. The policy also read, All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. The policy also read, Each resident will be evaluated for unique needs and performances to determine any special accommodations that may be needed in order for the resident to utilize the call system. The policy also read, Staff will ensure the call light is within reach of resident and secured, as needed. Resident #1 had diagnoses which included weakness and congestive heart failure. Resident #1's care plan 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 · D2024-12-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of misappropriation of resident property for one (#7) of three sampled residents reviewed for misappropriation of resident property. The administrator identified 74 residents resided in the facility. Findings: An undated ABUSE, NEGLECT, EXPLOITATION AND MISAPPROPRIATION OF PROPERTY PROHIBITION policy, read in part, The Facility will ensure a safe environment for residents by prohibiting abuse, neglect, exploitation and misappropriation of resident property with mechanisms for reporting, investigating, and protecting residents from actual or potential harm. Resident #7 had diagnoses which included hypertensive heart disease with heart failure. A nursing note, dated 08/03/24 at 1:50 p.m., documented the resident reported someone had moved their card in their wallet. They looked at their online banking and noticed that on 08/01/24 there were two withdrawals. One withdrawal was for $440 and one was for $500. An Initial State Reportable Incident form, dated 08/03/24,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-09 · tag F0773 — isolated
    Provide 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

    Based on record review and interview, the facility failed to ensure labs were not collected without a physician order for one (#6) of three sampled residents reviewed for lab services. The administrator identified 74 residents resided in the facility. Findings: The Lab and Diagnostic Test Results-Clinical Protocol policy, revised 09/2012, read in part, The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. Resident #6 had diagnoses which included chronic peripheral venous insufficiency and nonrheumatic mitral valve insufficiency. A lab report, dated 10/13/24, documented a CBC, CMP, HbA1c and prothrombin time with INR were collected. There was no physician order to collect the labs. On 12/05/24 at 12:43 p.m., the VP of clinical services stated they could not locate a lab order for the labs collected on 10/13/24 for Resident #6. On 12/05/24 at 12:46 p.m., the VP of clinical services stated the facility's process for laboratory services was to receive an order from the provider, contact the lab, verify completion, retrieve results,…

    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 · D2024-12-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure resident identifiable records were not released to the public. The administrator identified 74 residents resided in the facility. Findings: A Resident Rights Guidelines for All Nursing Procedures policy, dated 10/2010, read in part, Staff must have appropriate in-service training on resident rights, including; Confidentiality of protected health information; A HIPAA Training Program policy, dated 04/2007, read in part, All facility personnel, including business associates, are required to attend our facility's HIPAA compliance training program. On 11/27/24 at 3:24 p.m., the previous administrator stated the process for releasing medical records was that once the request form was signed it would go to the corporate office. They stated the corporate office then would decide if there would be a charge and then would send out the records themselves. They stated records were not sent out unless the corporate office stated to do so. They stated the corporate office gave direction to send the records for Resident #1 by…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-05-31 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 develop and implement a comprehensive care plan for two (#47 and #73) of 18 residents reviewed for care plans. The administrator identified 76 residents resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised 2016, read in part, the comprehensive care plan will describe, at a minimum .the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, the comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. 1. Resident #47 admitted on [DATE], had diagnoses that included sepsis, atrial fibrillation, and congestive heart failure. Resident #47's admission assessment documented resident #47 was on hospice services and required moderate to maximal assist with toileting, dressing, bathing, bed mobility, and was unable to walk. On 05/29/24 at 10:50 a.m., MDS #1 stated 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 before2024-05-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure incontinence care was provided in a timely manner for one (#24) of four dependent residents observed for timely overnight incontinence care. The administrator identified 48 residents were dependent for incontinence care. Findings: The Urinary Incontinence-Clinical Protocol policy, revised 2012, read in part, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Resident #24 was admitted [DATE] with diagnoses that included aphasia following cerebral infarction. Resident #24's quarterly assessment dated [DATE] documented they are unable to speak, can only sometimes understand, has severe cognitive impairments, functional impairments to all four extremities, requires tube feedings, and is dependent for all care. On 05/31/24 at 5:05 a.m., CNA #1 stated the policy is to check and change every 2 hours, but the staff is not supposed to use briefs at night unless 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 before2024-05-31 · 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 and interview, the facility failed to ensure: a.) notification of a change in condition of a wound for one (#2) of 14 residents who had wounds; and b.) a vascular surgeon consult was scheduled for one (#2) of 3 residents reviewed for hospitalizations. The Administrator identified 76 residents who resided in the facility. Findings: A Change in a Resident's Condition or Status policy, dated 2001, read in part, .Our facility shall promptly notify .Attending Physician .of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) .significant change in the resident's physical/emotional/mental condition .need to alter the resident's medical treatment significantly .specific instruction to notify the Physician of changes in the resident's condition .A significant change of condition is a major decline .in the resident's status that: will not normally resolve itself without intervention…

    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 · D2024-05-31 · tag F0847 — isolated
    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

    Based on record review and interview, the facility failed to explain the arbitration agreement in a manner the residents/representatives could understand for four (#27, #73, #228, and #238) of four sampled residents who entered into a binding arbitration agreement. The administrator identified 68 residents who had entered into a binding arbitration agreement. Findings: On 05/29/24 at 8:47 a.m., an example admission packet was reviewed. The arbitration agreement was set up as a DocuSign. On 05/30/24 at 2:35 p.m., during a resident council interview nine residents, including #27, #73, #228, and #238, stated they were unaware what an arbitration agreement was or if they had signed one. The ombudsman stated that on a lot of digital documents the programming would not let you continue if you did not sign. On 05/30/24 at 2:42 p.m., Residents #73 and #228 stated they would not have signed the arbitration agreement if they had known that they did not have to and that they were giving up their right to sue. Both also questioned why anyone would voluntarily give up any of their rights if 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-18 · tag F0580 — failed to tell family and doctor about changes — pattern
    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

    Based on record review and interview, the facility failed to notify the physician as ordered when FSBS were outside the ordered parameters for one (#131) of three sampled residents reviewed for insulin administration. The Administrator identified 14 residents with insulin parameter orders resided in the facility. Findings: A Diabetes - Clinical Protocol policy, revised 12/15, read in parts, .The Physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management .The staff will incorporate such parameters into the Medication Administration Records . Resident #131 had diagnoses which included type two diabetes mellitus with diabetic chronic kidney disease. A Physician Order, dated 03/16/23, documented inject Novolog insulin per sliding scale before meals and at hour of sleep. It documented if the FSBS was greater than 300, staff were to give eight units, notify the PCP, and recheck the FSBS in one hour. The March 2023 MAR documented the following FSBS with the Novolog insulin administration: a. On 03/21/23 at 8:00 p.m. FSBS…

    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 · E2023-04-18 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure medication was available to administer as ordered for two (#46 and #231) of six residents reviewed for medication administration. The Resident Census and Conditions of Residents report, dated 04/11/23, documented 77 residents resided in the facility. Findings: A Medication Ordering and Receiving from Pharmacy policy, revised January 2018, read in parts, .Medications and related products from the dispensing pharmacy on a timely basis .Reorder medications [three to four] days in advance of need .to assure an adequate supply is on hand . 1. Resident #46 had diagnoses which included fibromyalgia and gout. Resident #46's quarterly assessment, dated 12/26/22, documented the resident was cognitively intact, received scheduled and as needed pain medication. It documented they had frequent pain that limited their day to day activities. An active physician's order, dated 01/23/23, documented Oxycodone 10 mg give one tablet by mouth every four hours for pain. Resident #46's April 2023 MAR documented, see progress…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-18 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure medication carts left unattended were securely locked at all times for two of four treatment carts observed. The Resident Census and Conditions of Residents report, dated 04/11/23, documented 77 residents resided in the facility. Findings: A Security of Medication Cart policy, revised in April 2007, read in parts, .Medication cart must be securely locked at all times when out of the nurse's view .When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. 1. On 04/14/23 at 5:09 a.m., an unlocked and unattended treatment cart was observed on hall 300 with the next to last drawer slightly opened. Inside the cart was insulin pens and syringes, lancets, cards and bottles of medications, breathing treatment solutions, inhalers, creams and treatment supplies. There was no nurse near the cart or on the hall. On 04/14/23 at 5:33 a.m., RN #1 approached the cart and was asked if the cart was locked. They stated, No. RN #1 then locked the cart and 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a comprehensive resident assessment in a timely manner on admission for one (#131) of 18 sampled residents reviewed for resident assessments. The Resident Census and Conditions of Residents report, dated 04/11/23, documented 77 residents resided in the facility. The DON identified seven new admissions in the past 30 days. Findings: Resident #131 admitted to the facility on [DATE]. An admission Resident Assessment, dated 03/27/23, had a status of Export Ready. On 04/14/23 at 7:54 a.m., MDS Coordinator #1 was asked what the policy was for completing admission Resident Assessments. They stated for long term care admissions, the assessment reference date was due on the 14 day. They stated they had seven days after that to submit it. They stated they had 21 days to complete it. MDS Coordinator #1 was asked to review Resident #131's admission Assessment and explain what export ready meant. They stated the resident's assessment reference date was set…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    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 ensure bathing was provided for one (#231) of three sampled resident reviewed for bathing. The Resident Census and Condition of Residents report, dated 04/18/23, documented 42 residents required assistance of one to two staff and 26 residents were dependent on staff for bathing. Findings: A Quality of Life- Resident Self-Determination and Participation policy, revised 12/16, read in part, .1. Each resident is allowed to choose activities, schedules and healthcare that are consistent with his or her interest, values, assessments and plans of care, including: a. Daily routine, such as sleeping and walking, eating, exercise, and bathing schedules; b. Personal care needs, such as bathing methods, grooming, styles, and dress . Resident #231 had diagnoses which included dementia and chronic kidney disease. A comprehensive assessment, dated 03/18/23, documented Resident #231's cognition was severely impaired, ambulated with the assist of a cane, and required one person physical assist with bathing. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-18 · 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 — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure hair nets were worn in the kitchen by dietary staff. The DON identified 76 residents received nutrition from the kitchen. Findings: A facility Preventing Foodborne Illness - Employee Hygiene, and Sanitary Practices policy, undated, read in part, .Hairnets or caps and/or beard restraints must be worn to keep hair from contacting expose food, clean, equipment, utensils and linens . On 04/12/23 at 10:17 a.m., Dietary Aide #3 and Dietary Aide #4 were observed in the kitchen not wearing hair nets while washing dishes and preparing the lunch meal. On 04/12/23 at 10:20 a.m., Dietary Aide #4 was asked why they were not wearing a hair net while in the kitchen. The Dietary Aide #4 stated they did not have any available to wear. On 04/12/23 at 10:22 a.m., the CDM was asked why Dietary Aide #3 and Dietary Aide #4 were not wearing hair nets while in the kitchen. The CDM stated the hair nets were ordered from the food vendor and the hair nets never came in. The CDM was asked what was the policy for hair nets 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.

    Nutrition and Dietary 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

$35,311 in federal fines across 2 penalties.

  • $8,824 — penalty dated 2024-12-09
  • $26,487 — penalty dated 2024-08-20

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

Part of a chain

This home belongs to SOUTHWEST LTC — 10 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 2 of 52.4-0.4 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 5 of 52.4+2.6 vs chain
The other 9 homes this chain runs (chain average 2.4★, 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
QUALITY CARE GIVERS INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
RONALD R PAYNE PCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
SOUTHWEST LTC, LTDOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
BARONET, RODIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
BRASHIER, CRAIGIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
HINES, BARRYIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
PAYNE, RONALDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 04/27/2015
SOUTHWEST LTC MANAGEMENT SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2016

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$8.6M
Net patient revenuemost recent cost report
+4.4%
Operating marginrevenue minus expenses
$1.1M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 3%Other / private 46%

This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$289per resident / day
operating cost
$8,792per month
≈ monthly operating cost
$303per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375119. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, 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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