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Heritage Manor

3804 North Barr Ave, Oklahoma City, OK 73122 · For profit - Limited Liability company · 55 certified beds · (405) 789-7103 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Nov 20251 immediate-jeopardy citation$30,133 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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $30,133 in federal fines (most recent 2025-03-24)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (73%) 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.

1/5
CMS overall
1 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 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4100 Perimeter Center Dr Ste 270 · (405) 534-1888 · Call to confirm hours
Pharmacy
4026 N MacArthur Blvd · (405) 789-0101 · Call to confirm hours
Grocery
3925 N MacArthur Blvd · (405) 603-2623 · Call to confirm hours
Park
3100 N Grove Ave · (405) 297-3882 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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 rating2★
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 increased10.4%13.6%15.4%better
Long-stay residents who lose too much weight9.0%3.3%5.4%worse
Long-stay residents with a catheter left in their bladder2.2%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection4.4%2.8%2.0%worse
Long-stay residents with depressive symptoms0.7%3.4%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.5%4.7%3.3%worse
Long-stay residents whose ability to walk worsened11.7%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.0%25.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.6%95.3%typical
Long-stay residents with pressure ulcers6.3%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control5.0%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.1%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 vaccine47.8%74.1%79.4%worse
Short-stay residents rehospitalized after admission32.0%27.3%22.6%worse
Short-stay residents with an outpatient ER visit15.5%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.022.311.67worse
Long-stay outpatient ER visits per 1,000 resident days3.052.961.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 identified100.0%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 worsened9.7%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 SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.29
RN hours/ resident / day
0.82
LPN hours/ resident / day
1.76
Aide hours/ resident / day
2.87
Total nurse hours/ resident / day
0.23
RN hoursweekends
72.7%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 55 beds and averages 48.7 residents a day — about 89% occupied, or roughly 6 beds typically open. It runs fairly full. 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 2.87 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 2.41 hrs/resident/day on weekends vs 3.06 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.31 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 73% 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

6
deficiencies at the latest standard inspection (2025-11-21)
13
at the previous standard inspection (2024-05-23)

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.

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-03-24 · 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 03/19/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision for Resident #1 who wandered and experienced exit seeking behaviors. An undated elopement policy, read in part, It is the policy of this facility to provide a safe and comfortable environment to prevent resident elopements. Resident #1's Wandering Risk Assessment, dated 02/13/25, showed the resident was a high risk for wandering and was a known wanderer/history of wandering. A nurse note, dated 02/15/25 at 1:03 p.m., showed Resident #1 remains confused trying to exit pushing on north hall door. The note showed Resident #1 was wandering on other halls and went in other rooms. An admission resident assessment, dated 02/19/25, showed Resident #1's BIMS score was 00 (severe cognitive impairment) and the resident was independent for the task of sit to stand and walking 10 feet, 50 feet with two turns, and 150 feet. A nurse note, dated 02/19/25 at 8:35 p.m., read in part, At about [8:35…

    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 · Gcited before2024-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure: a. falls were evaluated for cause and interventions implemented to prevent falls with injuries for one (#48) of three sampled residents reviewed for accident hazards and falls. Resident #48 had a fall with a major injury in December 2023 which resulted in staples to the head. The facility did not assess the fall and implement changes in interventions to aide in the prevention of falls. Resident #48 had two additional falls one in March 2024 and one in April 2024 that also resulted in injuries without any implemented changes to interventions to aide in the prevention of falls. b. care plan interventions were implemented for one (#32) of three sampled residents reviewed for accident hazards and falls. The facility Centers for Medicaid and Medicare from 802 , documented 6 residents had falls with injuries and two had falls with major injuries. Findings: 1. Resident #48 had diagnosis that included Schizophrenia, dementia, unspecified psychosis, abnormal coagulation, and acute kidney failure. Residents #48…

    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 before2026-05-22 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a medication cart was supervised and locked for 1 (medication cart #1) of 2 medication carts observed. The ADON identified 48 residents resided in the facility and there were two medication carts. Findings:On 05/19/26 at 4:43 p.m., medication cart #1 on the south hall by the nurse's station was observed to be unlocked and unattended. There was no staff in sight of the medication cart.On 05/19/26 at 4:44 p.m., the ADON was observed walking to the unlocked medication cart #1 on the south hall by the nurse's station and then left without locking the medication cart. On 05/19/26 at 4:45 p.m., CMA #1 was observed walking out of a resident's room on the north hall to medication cart #1 on the south hall. Medication cart #1 was unlocked and unattended. Medication cart #1 remained unlocked, out of sight and supervision, while CMA #1 was away from the medication cart. A facility policy titled Security of Medication Cart, revised April 2007, read in part, 4. Medication carts must be securely locked at all times…

    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 · F2025-11-21 · tag F0847 — widespread
    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 ensure residents or their representatives:Understood what an arbitration agreement was;Understood their right not to sign the agreement as a condition of admission, or as a requirement to continue to receive care at the facility; andWere explicitly granted the right to rescind the agreement within 30 calendar days of signing the document for 8 (#1, 2, 27, 38, 39, 42, 45, and #51) of 8 sampled residents reviewed for arbitration agreements.The administrator identified 51 residents resided in the facility.The social services director stated all 51 residents had entered into a binding arbitration agreement.Findings:On 09/30/25 at 12:15 p.m., the social services director was observed using Docusign to click through the sections of the admission agreement. Hitting the enter button would sign each section and move to the next, thereby agreeing to everything inside of the admission packet. The arbitration agreement was part of the admission packet and was agreed to upon admission for everyone admitted to the facility.An undated,…

    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 · F2025-11-21 · tag F0848 — widespread
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure the arbitration agreement provided:the selection of a neutral arbitrator agreed upon by both parties; andfor the selection of a venue that is convenient to both parties.The administrator identified 51 residents resided in the facility.The social services director stated all 51 residents had entered into a binding arbitration agreement.Findings:An undated Dispute Resolution Plan, contained within the Admissions Agreement: Manor, read in part, The parties agree and acknowledge that the business relationship involves interstate commerce and that any such mediation or arbitration shall be governed by the Federal Arbitration Act (FAA) and conducted in accordance with the Rules of Mediation and Arbitration as then in effect and administered by Dispute Solutions, Inc.On 10/01/25 at 12:15 p.m., the social services director stated they went through each area of the admission packet separately, and they have not had a problem with people agreeing to sign the arbitration agreement.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-21 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete the advance directive acknowledgement for 3 (#1, 2, and #42) of 13 sampled residents reviewed for advance directive acknowledgements.The administrator identified 51 residents resided in the facility.Findings:An Advance Directive policy, revised 2016, read in part, Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.An Advance Directive Acknowledgement form, read in part, Please check ONE of the following statements: I HAVE executed and Advance Directive. I HAVE NOT executed an Advance Directive.Resident #1's Advance…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to store and maintain food and ice in a safe manner for one ice machine and 2 of 3 freezers maintained in the dining room. The administrator identified 51 residents resided in the facility. Findings:On 09/29/25 at 11:30 a.m., an observation of the kitchen and dining room was completed. In the corner of the dining area were three freezers and an ice machine. Two of the three freezers and the ice machine were not locked. Residents were walking around in the dining area waiting for the noon meal. There was no signage for staff use only. A facility policy titled Ice Machines and Ice Storge Chests read in part, To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions .Limit access to ice machines or ice storage chests/containers to employees only.A facility policy titled PURCHASING, RECEIVING AND STORAGE, read in part, Food will be properly stored to preserve flavor, nutritive value, appearance, and safety. Only authorized personnel will have access 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · 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 thoroughly investigate an allegation of abuse for 1 (#59) of 1 sampled resident reviewed for abuse.The administrator identified 10 allegations of abuse in the last six months.Findings: An undated electronic clinical record for Resident #59, under the tab medical diagnosis, showed diagnoses of hemiplegia and hemiparesis following cerebral infarction, aphasia, and diabetes.A facility policy titled Abuse Investigation and Reporting, revised July 2017, read in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.The individual conducting the investigation, as a minimum.interview the person(s) reporting the incident,.interview the resident (as medically appropriate),.interview staff members (on all shifts) who have had contact with the resident during the period of the alleged…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure two opened multidose vials of PPD solution were labeled with the date of the first usage for 1 of 1 refrigerators observed. Findings: A policy titled Dating and Discarding of Multidose Parenteral Vials, dated 06/21/17, read in part, If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days for the opened vial.On 09/30/25 at 9:53 a.m. an observation of the medication storage room was performed with LPN #3. Two multidose vials of Tuberculin PPD were opened and not dated. On 09/30/25 at 9:53 a.m., LPN #3 was asked what their policy on opened vials of medication was. LPN #3 stated the vials should have a date on them when they were opened.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-24 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 privacy curtain was utilized during personal care for one (#9) of three sampled residents observed receiving incontinent care. The AIT identified 44 residents resided in the facility. Findings: An undated PERI CARE policy, read in part, Provide privacy, ensure door is closed, privacy curtain is pulled to provide full visual privacy and window blinds are closed. Resident #9 had diagnoses which included generalized muscle weakness and cerebral infarction. Resident #9's annual resident assessment, dated 09/17/24, documented they had severe cognitive impairment. Resident #9's care plan for ADL deficit, revised 10/10/24, documented they required total assist with toileting. On 10/22/24 at 2:59 p.m., CNA #1 entered Resident #9's room to provide incontinent care. CNA #1 closed the door. The resident's roommate was in the room in their wheelchair. On 10/22/24 at 3:00 p.m., CNA #1 told the resident they would be providing care. CNA #1 provided incontinent care to the resident. The privacy curtain was not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · 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 observation, record review, and interview, the facility failed to ensure thorough incontinent care was provided for one (#9) of three sampled residents observed receiving incontinent care. The AIT identified 44 residents resided in the facility. Findings: Resident #9 had diagnoses which included generalized muscle weakness and cerebral infarction. Resident #9's annual resident assessment, dated 09/17/24, documented they had severe cognitive impairment. Resident #9's care plan for ADL deficit, revised 10/10/24, documented they required total assist with toileting. On 10/22/24 at 2:59 p.m., CNA #1 entered Resident #9's room to provide incontinent care. They closed the door. On 10/22/24 at 3:00 p.m., CNA #1 told Resident #9 they would be providing care. CNA #1 had on gloves. They partly removed the resident's soiled brief, turned the resident on their side, and cleansed their buttocks. Fecal matter was observed during cleaning. CNA #1 removed the soiled brief and put it in a trash bag. They put the soiled pad on the floor mat. CNA #1 put a new brief on the resident and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to maintain infection control during the provision of incontinent care for one (#9) of three sampled residents observed receiving incontinent care. The AIT identified 44 residents resided in the facility. Findings: Resident #9 had diagnoses which included generalized muscle weakness and cerebral infarction. Resident #9's annual resident assessment, dated 09/17/24, documented they had severe cognitive impairment. Resident #9's care plan for ADL deficit, revised 10/10/24, documented they required total assist with toileting. On 10/22/24 at 2:59 p.m., CNA #1 entered Resident #9's room to provide incontinent care. They closed the door. On 10/22/24 at 3:00 p.m., CNA #1 told Resident #9 they would be providing care. CNA #1 had on gloves. They partly removed the resident's soiled brief, turned the resident on their side, and cleansed their buttocks. Fecal matter was observed during cleaning. CNA #1 removed the soiled brief and put it in a trash bag. They put the soiled pad on the floor mat. They put a new brief on 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · F2024-05-23 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to submit accurate payroll based journal staffing data to CMS for FY quarter 1 2024. LPN #3 identified 51 residents resided in the facility. Findings: A PBJ Staffing Data Report dated 10/01/24 through 12/31/24, documented the facility did not have RN hours for 10/22, 10/23, 11/03, 11/10, 11/17, 11/30, 12/01, 12/04, 12/07, 12/08, 12/09, 12/10, 12/22, 12/23, 12/24, 12/25, and 12/30/24. The report documented the facility did not have licensed nursing coverage for 24 hours/day for 12/09, 12/10, 12/23, and 12/24/24. On 05/23/24 at 8:31 a.m., Corporate Nurse Consultant #1 stated we had the hours they just didn't get on the report. On 05/23/24 at 1:14 p.m., the Operations Manager provided documentation of coverage for the dates above.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to provide a SNF ABN to one of three residents reviewed for beneficiary notification. LPN #3 identified 51 residents resided in the facility. Findings: The Regional MDS Specialist identified 12 residents who had been discharged from a Medicare Part A covered stay with benefit days remaining in the past 6 months. Resident #206 admitted to Part A skilled services on 11/16/23 and discharged from Part A services on 12/05/24. There was no documentation a SNF ABN was provided to resident #25. On 05/20/24 at 2:23 p.m., the Regional MDS Specialist stated they had completed the SNF benefit review and Resident #206 did not have a notice issued. They stated there should have been a notice issued for Resident #206.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure room [ROOM NUMBER] was free of odors for one (#29) of 30 rooms observed for odors. The facility operations manager identified 30 rooms in the facility that were occupied by residents. Findings: On 05/19/24 from 8:30 a.m., through 1:15 p.m., there was a strong odor of urine coming from room [ROOM NUMBER]. When the rooms door was open it could be detected down the hall approximately six feet from the room. On 05/20/24, 05/21/24, 05/22/24 and 05/23/24, the same observations were made of the room. On 05/23/24 at 1:10 p.m., Housekeeper #1 stated room [ROOM NUMBER] has had a strong urine odor since they stated work at the facility the first of March, 2024. They stated the room is cleaned twice a day and the tile has been replaced and they still can not keep up with the urine odor in the room. On 05/23/24 at 1:18 p.m., the Housekeeping Supervisor stated they made rounds twice a day to ensure rooms were being cleaned. The supervisor stated they clean room…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 the cognitive pattern, section (C), of the minimum data set was coded for one (#42) of 13 sampled residents whose MDS were reviewed. LPN #3 identified 51 residents currently resided in the facility. Findings: Resident # 42 had diagnosis to include schizophrenia, angina, cerebral infarction, restlessness and agitation, hypertension, acute kidney disease, psychosis and diabetes mellitus. A quarterly assessment dated [DATE], under section C cognitive patterns had dashes located in every box. There were no documented answerers to any of the questions located in section C of the assessment. On 05/22/24 at 1:02 p.m., [NAME] Nurse Consultant #2, the intern DON, stated sections C should have been completed and the Regional MDS coordinator would be able to tell why it was not. He stated without it being filled out it was not accurate. On 05/23/2024 at 10:09 a.m., The Regional MDS coordinator stated section C had dashes which indicated the section was not…

    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 · E2024-05-23 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reciew and interview, the facility failed to ensure care plans were reviewed every three months for three (#12, #42, and #48) of 13 resident care plans reviewed. LPN #3 identified 51 residents resided in the home. Findings: 1. Resident #12 had diagnosis to include unspecified skin condition, peripheral vascular disease, and non-pressure ulcers. Resident #12 care plan was last reviewed on 03/11/23. 2. Resident # 42 had diagnosis to include schizophrenia, angina, cerebral infarction, restlessness and agitation, hypertension, acute kidney disease, psychosis and diabetes mellitus. Resident #42 care plan was last reviewed on 05/04/2023. 3. Resident #48 had diagnosis that included Schizophrenia, Diabetes Mellitus, unspecified psychosis, abnormal coagulation, and acute kidney failure. Resident #48 care plan was last reviewed on 08/14/23. On 05/23/24 at 11:06 a.m., the Regional MDS Coordinator was asked how often care plans were to be reviewed. They stated quarterly, every three months and a comprehensive care plan annually. The Regional MDS Coordinator reviewed the care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to: a. ensure a trauma wound to the left second toe was changed as needed when viably soiled and not intact for one (#12) of one sampled resident reviewed for trauma injury to the feet.; and b. accurately document behaviors to support the administration of as needed antianxiety medication for one (#29) of one sampled resident receiving as needed antianxiety medication. LPN #3 identified 51 residents resided in the facility. Findings: An Administering Medications policy, revised April 2019, read in parts, As required or indicated for a medication, the individual administering the medication records in the resident's medical record .any complaints or symptoms for which the drug was administered .any results achieved and when those results were observed . 1. Resident #12 had diagnosis to include unspecified skin condition, peripheral vascular disease, and non-pressure ulcers. The current physician orders for Resident #12 documented the following treatment order: cleanse left second toe area with non-saline, apply…

    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 · E2024-05-23 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    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 implement a weight loss intervention of shakes three times a day timely for one (#48) of one resident reviewed for weight loss. The facility Centers for Medicaid and Medicare from 802 , documented 3 residents had excessive weight loss. Findings: Resident #48 had diagnosis that included Schizophrenia, Diabetes Mellitus, unspecified psychosis, abnormal coagulation, and acute kidney failure. A care plan last updated on 05/18/23, documented the resident was at risk for weight loss and had a history of severe weight loss. A documented intervention was to have the registered dietician to evaluate and make diet change recommendations. A review of Resident #48 weight record, dated 03/29/24, documented the resident weighed 158.2 pounds. The weight record also documented the resident had a severe weight loss of 32 pounds (16.8%) in 180 days from 10/25/23 to 03/29/24; and a severe weight loss of 11 pounds (6.5%) in 30 days from 02/23/24 to 03/29/24. A consulting dietician recommendation, dated 04/01/24, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 there was sufficient staff and supervison for the needs of the residents. LPN #3 identified 51 residents resided in the facility. Findings: 1. Resident #48 had diagnosis that included Schizophrenia, dementia, unspecified psychosis, abnormal coagulation, and acute kidney failure. Residents #48 care plan, last revised on 05/18/23, read in part, .Focus .[Resident #48] is at risk for falls r/t history of falls, poor safety awareness, impaired cognition/dementia, confusion and delusional thought processes .Interventions .Remind/encourage/cue him to use his walker when ambulating to reduce risk of falling .Check on resident every 2 hours and .PRN . A progress note, dated 12/02/23 at 1:39 a.m., read in part, .This nurse heard the CNA holler out for help to get res out of another res room. As I was walking down the hall I witnessed the res fall backwards into the hall hitting his head on the floor. Res began to bleed profusely. Pressure and ice applied immediately .sent to ER .for eval and treat . A 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure staffing information was posted with the required components and was accessible to all residents. LPN #3 identified 51 residents who resided in the facility. Findings: On 05/19/24 at 8:00 a.m., there was no staff information observed posted in the facility. On 05/20/24 from 8:00 a.m. through 2:30 p.m., there was no staff information observed posted in the facility. On 05/21/24 at 6:15 a.m., there was no staff information observed posted in the facility. On 05/21/24 at 6:57 a.m., the operations manager stated the staffing should be posted on the large white dry erase board near the nurses station. The operations manager than stated after observing the blank board they did not know it was a requirement the information had to be posted.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide education and consent before administration of the influenza vaccine for four (#12, 15, 23, and #32) of five residents reviewed for immunizations. LPN #3 identified 51 residents resided in the facility. Findings: (a) Resident #12's signed consent for influenza shot was dated 10/04/23. Their immunization record documented influenza shot was given to resident on 10/03/23. (b) Resident #15's signed consent for influenza shot was dated 04/19/24. Their immunization record documented influenza shot was given to resident on 10/03/23. (c) Resident #23's signed consent for influenza shot was dated 10/04/23. Their immunization record documented influenza shot was given to resident on 10/03/23. (d) Resident #32's signed consent for influenza shot was dated 10/04/23. Immunization record documented influenza shot was given to resident on 10/03/23. On 05/23/24 at 11:05 a.m., Regional Nurse Consultant #1 was asked when residents or their responsible parties are offered the influenza vaccine and educated on the risk and benefits.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide education and consent before administration of the COVID-19 vaccine for three (#12, 23, and #32) of five residents reviewed for immunizations. LPN #3 identified 51 residents resided in the facility. Findings: (a) Resident #12's immunization record documented a COVID-19 vaccination was administered to resident on 04/23/24. There was no signed consent nor documentation that education on the risks and benefits of the vaccination had been provided to the resident or their representative in the clinical record for Resident #12. (b) Resident #23's immunization record documented a COVID-19 vaccination was administered to resident on 04/23/24. There was no signed consent nor documentation that education on the risks and benefits of the vaccination had been provided to the resident or their representative in the clinical record for Resident #23. (c) Resident #32's immunization record documented a COVID-19 vaccination was administered to resident on 11/30/22. There was no signed consent nor documentation that education on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    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 discharge planning was completed prior to discharge for one (#55) of one sampled resident discharged from the facility into the community. The Regional Nurse Consultant #1, identified four residents who discharged into the community in the last six months. Findings: A communication progress note, dated 03/20/24 at 9:45 a.m., documented Resident #55 wanted to discharge from the facility at the end of the month into the community with a friend. There was no documentation in the clinical record the facility made arrangements for medical services, pharmacy services and or any other follow up appointments. An activity progress note, dated 03/27/24 at 12:23 p.m., documented Resident #55 was looking forward to their discharge from the facility. A nurse's progress note, dated 04/01/24 at 1:49 p.m., documented the resident discharged from the facility in the morning with all belongings and medications. A social service progress note, dated 04/01/24 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-08 · 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 and interview, the facility failed to ensure a bath/shower was provided to a resident who required assistance from staff for one (#3) of three sampled residents reviewed for ADL assistance. The administrator identified 51 residents resided in the facility. Findings: The Activities of Daily Living (ADLs), Supporting policy, revised 03/18, read in part, .care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with .bathing . Resident #3 had diagnoses which included end stage renal disease and pain. Resident #3's admission resident assessment, dated 07/27/23, documented Resident #3's cognition was intact and they required limited assistance from another person for transfers during bathing. A Documentation Survey Report v2, dated July 2023, documented Resident #3's bathing schedule was Monday, Wednesday, and Friday. The report documented the Resident had not received a bath, one out of four opportunities. The report documented blank for 07/28/23. A Documentation Survey Report v2,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-10 · 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 record review, observation, and interview, the facility failed to ensure bathing was offered to residents (#8 and #46) of six sampled residents reviewed for bathing. The Resident Census and Conditions of Residents report, dated 04/06/23, documented 54 residents resided in the facility. Findings: 1. Resident #8 had diagnoses which included paranoid schizophrenia, morbid obesity, COPD, and spondylosis. Resident #8's care plan initiated 08/04/22 documented bath/shower 3x weekly. Resident #8's Bath Schedule sheets provided for the month of October 2022 documented six showers offered out of 12 opportunities. Resident #8's Bath Schedule sheets provided for the month of November 2022 documented nine showers offered out of 13 opportunities. Resident #8's Bath Schedule sheets provided for the month of December 2022 documented 10 showers offered out of 14 opportunities. Resident #8's Bath Schedule sheets provided for the month of January 2023 documented one shower offered out of 13 opportunities. Resident #8's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed ensure: a. clean dishes were stored on sanitary clean rust free surfaces away from unsanitary wash sinks, b. trash was disposed of in a covered trashcan in the kitchen and, c. the ice machine was cleaned and sanitary. The Administrator identified 52 residents received nutrition form the kitchen. The Resident Census and Condition of Residents, dated 04/06/23, documented 54 residents resided in the facility. Findings: A DRY STORAGE- DISHES AND UTENSILS policy, undated, read in part, .Enclosed storage will be provided for clean and sanitized dishes and utensils .Storage areas will be cleaned and sanitized .Dish storage areas will be kept closed and covered when not in use . A Cleaning Policies and Procedures document, undated, read in part, .all surfaces must be cleaned on a routine basis .once equipment and utensils have been sanitized, they should be handled and stored to protect the equipment and utensils from re-contamination . A Sanitation, policy, undated, read in part, .The food service supervisor will…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to provide maintenance repairs to ensure: a. water damaged sheetrock and missing baseboards in the dining room were repaired and b. paint on the wall on the halls and door frames was not peeled, chipped, and/or scuffed. The Resident Census and Condition of Residents, dated 04/06/23, documented 54 residents resided in the facility. Findings: On 04/10/23 at 3:00 p.m.,The front commons area paint was scraped from the walls in entry area outside the Administrators office, the east hall walls were scuffed with black marks, paint was chipped, missing, and scuffed with black marks on the south east blue hall and black marks and scuffs were on the dining room walls and door trims, and the base boards were missing with visible water damage to the sheetrock in dining area was observed. On 04/10/23 at 3:06 p.m.,The Corporate Maintenance was asked if the missing paint , scuffed walls, missing base boards and damaged sheetrock in the dining room and scratched and scuffed paint in the front common areas and halls facilitated a home like…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-10 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to have a registered nurse as a DON (Director of Nursing) on a full-time basis for eight hours a day five days a week. The Resident Census and Conditions of Residents report, dated 04/06/23, documented 54 residents resided in the facility. Findings: The facility's previous DON time cards provided for dates 10/01/22 through 02/10/23 documented the following : 1. 10/03/22 through 10/07/22 documented 32.39 hours worked. 2. 10/17/22 through 10/21/22 documented 38.40 hours worked. 3. 10/31/22 through 11/04/22 documented 38.54 hours worked. 4. 11/21/22 through 11/25/22 documented 25.03 hours worked. 5. 12/12/22 through 12/16/22 documented 32.58 hours worked. 6. 12/26/22 through 12/30/22 documented 32.17 hours worked. 7. 01/02/23 through 01/06/23 documented 32.35 hours worked. 8. 01/30/23 through 02/03/23 documented 38.51 hours worked. On 04/05/23 at 9:11 a.m., the Corp. Nurse Consultant #1 stated the current DON was corporate CNO who had taken over as interim DON. On 04/10/23 at 5:08 p.m., the interim DON was asked who was 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-10 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 maintain an effective pest control program for one (#104) of 12 sampled residents reviewed for pest. The Resident Census and Condition of Residents, dated 04/06/23, documented 54 residents resided in the facility. Findings: A Pest Control Program, policy undated, read in part, .It is the policy of [named facility] to maintain an effective pest control program that eradicating contains common household pest, and rodents .Facility will utilize a variety of methods and controlling certain seasonal pest, i.e. flies. These will involve outdoor and indoor methods that are deemed appropriate by the outside pest service and state and federal regulations . On 04/06/23 at 8:51 a.m., Resident # 104 pointed to a sticky fly trap pinned to the ceiling hanging about 24 inches down at the foot of the Resident # 104 bed and stated, what is that up there never seen in my life. A sticky fly trap was observed covered with dead flying insects identified as flies. Resident #104 stated the item was there when they admitted 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.

    Environmental 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

$30,133 in federal fines across 2 penalties.

  • $8,323 — penalty dated 2025-03-24
  • $21,810 — penalty dated 2024-05-23

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

Who owns this facility

Owner / managerTypeRoleShareSince
HOLLAWAY, CHRISTIANIndividualDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2024
UNDERWOOD, ADAMSONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF49%since 04/01/2024
VOYAGE MANAGEMENT OF OK, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/19/2024
JOHN, TENEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2024
MARCUM, NEDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/14/2024
JUDY M CRANE LIVING TRUSTOrganizationADP OF THE SNFsince 10/15/2024
MANOR HOME PROPERTY, LLCOrganizationADP OF THE SNFsince 11/19/2024

CMS files one row per role, so the 17 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$4.9M
Net patient revenuemost recent cost report
+5.3%
Operating marginrevenue minus expenses
$202K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 90%Medicare 4%Other / private 6%

About 90% 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 $202K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$242per resident / day
operating cost
$7,366per month
≈ monthly operating cost
$256per 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 375502. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, 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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