Meadowlake Estates
959 Southwest 107th Street, Oklahoma City, OK 73139 · For profit - Corporation · 124 certified beds · (405) 703-3400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $23,611 in federal fines (most recent 2025-01-06)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (59%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 1.3% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.0% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.9% | 3.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 4.7% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.4% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.7% | 25.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 2.4% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.2% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 73.3% | 74.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 37.3% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.5% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.63 | 2.31 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.01 | 2.96 | 1.80 | better |
‡ 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.
55.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 17.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.9%CMS range 47.0–64.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 6.7–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 17.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 21.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 14.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 91.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 3.5–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 124 beds and averages 111.5 residents a day — about 90% occupied, or roughly 12 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 2.89 hrs/resident/day on weekends vs 3.57 on weekdays — 19% thinner on weekends. RN hours go from 0.28 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · J2025-01-06 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
On 01/03/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to follow Resident #10's minced and moist level 5 diet which resulted in the resident choking. A physician's order, dated 11/29/24, documented Resident #10 was to have a minced and moist level 5 diet. An incident report, dated 12/19/24, documented Resident #10 was eating lunch in their room when a medication aide saw that the resident was choking and alerted the nurse who performed the Heimlich maneuver. It documented the brownie was expelled. It documented the nurse practitioner was notified and a x-ray was ordered. It documented family was notified. It documented the facility investigated and determined Resident #10 was given a brownie that was not on their diet. It documented the nurse stated the resident was still moving air and coughing and was able to cough the brownie up with a gentle Heimlich maneuver. It documented the dietary manager was notified and kitchen staff were in-serviced on following the resident's diet on their diet sheet. It documented the resident would…
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.
- Immediate jeopardy · K2023-09-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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
On 09/14/23 at 10:50 a.m., the Oklahoma State Department of Health (OSDH) confirmed the existence an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure residents were not missing from the facility. On 09/08/23 the facility was notified by someone in the community that Resident #8 was outside behind the facility on the ground. During an interview with LPN #1, they stated Resident #8 had been outside 30 minutes or less. They stated Resident #8 was found with wet muddy shoes and pants. They stated the resident was able to exit through the back door that went to the smoking area due to the door being broke, and the code and alarm do not work. LPN #1 stated it appeared that the resident had exited a gate behind the facility, as it was found to be open when they went to the back where Resident #1 was located in the alley behind the facility. On 09/14/23 at 10:50 a.m., the administrator was informed of the immediate jeopardy situation. On 09/14/23 at 6:02 p.m., an acceptable plan of removal was received. The plan of removal documented:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure medications were stored securely to prevent unauthorized access during 1 of 2 observations of medication storage.The DON identified 109 residents received medication from the facility.Findings:On 03/25/26 at 10:25 a.m., a white pill identified as a 100 mg gabapentin (an anticonvulsant) was observed laying on top of a medication cart in the hall outside of a resident's room. There was no staff in sight of the medication cart.A facility policy titled Medication Administration General Guidelines, dated 01/2024, read in part, 17. During administration of medications, the medications cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering the medications when unlocked.On 03/25/26 at 10:30 a.m., the DON was shown the pill located on top of the medication cart. The DON stated the pill was a 100 mg gabapentin (an anticonvulsant). The DON stated a resident could have picked up the pill…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-12 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 residents were bathed as scheduled for 1 (#1) of 5 sampled residents reviewed for assistance with ADLs. The DON identified 114 residents who resided in the facility. Findings: On 03/11/25 at 12:25 p.m., Res #1 was observed lying in bed. The resident's hair was braided and kempt. No odors were observed. A policy titled Bathing, revised 02/12/20, read in part, Staff will provide bathing services for residents within standard practice guidelines .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record. Res #1 was admitted with diagnoses which included quadriplegia, multiple sclerosis, and muscle wasting. A quarterly assessment, dated 11/22/24, showed Res #1 had a brief interview for mental status score of 15 and was cognitively intact. The assessment showed Res #1 was dependent with bathing and mobility. A care plan, dated 12/18/24, showed the resident preferred to be bathed in the morning and for staff to provide the resident assistance with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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: a. provide incontinent care to prevent a moisture associated pressure ulcer for 1 (#5); and b. ensure care was provided as ordered by the physician for 1 (#6) of 3 residents sampled for ADL care to prevent/worsening of pressure ulcers. The DON reported 114 residents resided in the facility. Six residents had wounds. Findings: A facility policy titled Prevention of Pressure Ulcers/Injuries, dated July 2018, read in part,Based upon the assessment and the resident's clinical condition, choices and identified needs, basic or routine care could include, but is not limited to, interventions to: a. Redistribute pressure (such as repositioning, protecting and/or offloading heels); b. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. 1. Res #5 admitted with diagnoses of muscle wasting and atrophy, major depressive disorder, and muscle weakness. An Incident Investigation Report, dated 02/23/24, read in part, On 02/23/25, it was reported by the 11-7 nurse that the residents: [Res…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 ensure: a. raw meat items were stored in a manner to prevent cross contamination; b. dented cans were removed from circulation in the dry storage; c. leftover food items were discarded within the appropriate timeframe; d. food items in the refrigerator were stored in a sealed container; e. expired food items were removed from circulation; and f. food items were appropriately dated and labeled during the kitchen observation. The DON identified 106 residents received services from the kitchen. Findings: A Use of Leftovers policy, dated 08/01/18, read in parts, Leftovers will be properly handled and used .Leftovers should be covered, labeled, dated and stored appropriately .Unless otherwise indicated on package, leftover food is used within 72 hours or discarded. A Food Storage policy, dated 08/01/18, read in parts, Storeroom .Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened .All stock is rotated with each new order received…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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: a. provide incontinent care in a manner which prevented cross contamination for two (#33 and #42) of four sampled residents observed during incontinent care; b. handle linens in a manner which prevented cross contamination for one (#42) of four sampled residents observed during incontinent care; c. ensure proper PPE was worn in a room with a COVID-19 positive resident for three (#46, 55 and #89) of three sampled residents observed with COVID-19; d. ensure the same PPE was not worn when assisting two different residents with COVID-19 in the same room for two (#46 and #55) of three sampled residents observed with COVID-19; and e. medications were not handled with bare hands. The DON identified 67 incontinent residents and four Covid-19 positive residents resided in the facility. ADON #1 identified 111 residents resided in the facility. Findings: A Perineal Care/Incontinent Care policy, effective 04/2012, read in parts, Staff will perform…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-06 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure MDS entry tracking was completed per RAI guidelines for one (#45) of 27 sampled residents who were reviewed for resident assessments. ADON #1 identified 111 residents resided in the facility. Findings: A Resident Assessment policy, revised 01/12/20, read in parts, Purpose: To enter this assessment data into a computerized format that will be transmitted to the Center for Medicare/Medicaid Services (CMS). The policy also read, Tracking records .will be transmitted electronically, in a CMS specified format. Resident #45's MDS list documented a discharge return anticipated on 05/19/23. It documented a quarterly assessment dated [DATE]. There was no entry tracking record. On 12/31/24 at 10:42 a.m., the clinical reimbursement specialist stated the resident went to the hospital and did need an entry. They stated the RAI was not followed.
- Potential for harm · D2025-01-06 · tag F0641 — isolatedEnsure 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 resident assessments were accurately coded for one (#111) of 27 sampled residents reviewed for resident assessments. ADON #1 identified 111 residents resided in the facility. Findings: A Resident Assessment policy, revised [DATE], read in part, Each individual who completes a portion of the assessment will sign to certify the accuracy of that portion of the assessment. Resident #111 had diagnoses which included history of seizures and history of traumatic brain injury. A Nurse Note, dated [DATE], documented at 5:25 p.m., Resident #111 coded, CPR was started, emergency personnel arrived, and eventually restored Resident #111's pulse. It documented Resident #111 transferred from the facility to the hospital. The note was electronically signed by the DON on [DATE]. A Transfer Form, dated [DATE], documented Resident #111's blood pressure was 147/79, pulse 68, respirations 18, oxygen 95 percent, and the resident was transferred to the hospital.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to provide incontinent care in a manner to prevent UTI's for one (#42) of four sampled residents observed during incontinent care. The DON identified 67 incontinent residents resided in the facility. Findings: A Perineal Care/Incontinent Care policy, effective 04/2012, read in parts, Staff will perform perineal/incontinent care with each bath and after each incontinent episode .Clean groin using sweeping motion .For female .Separate labia and wash downward .then downward on each side of the labia using a different peri wipe with each stroke .Wash downward toward the base of the vaginal opening .Remove gloves and wash hands or alcohol gel and re-glove hands .Turn resident on side facing staff. Roll soiled brief/incontinent pad and apply clean brief and/or incontinent pad. Turn resident away from staff. (ONLY USE ONE WIPE PER SWIPE) .Clean outer hip of buttocks going upwards towards back .Clean anal area with upward motion .Remove gloves and wash hands with alcohol gel. Resident #42 had diagnoses which included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 oxygen was administered as ordered and a concentrator had a filter and was dust free for one (#1) of one sampled resident reviewed for respiratory care. The DON identified 24 residents who received oxygen therapy in the facility. Findings: The OXYGEN THERAPY, CONCENTRATOR INITIATION policy, revised 01/12/20, read in part, The licensed staff will provide the prescribed amount of oxygen therapy to the residents as prescribed by physician and according to practice guidelines. Resident #1 had a diagnosis of chronic obstructive pulmonary disease. A physician's order, dated 12/27/24, documented oxygen 2 liters per minute inhalation every shift via nasal cannula, may remove for ADLs. On 12/30/24 at 11:58 a.m., Resident #1 was observed receiving oxygen via a nasal cannula. The concentrator vent had extreme dust build up. On 01/02/25 at 11:33 a.m., Resident #1 was observed receiving oxygen via a nasal cannula at 3 liters per minute. On 01/02/25 at 1:32 p.m., RN #1 reviewed Resident #1's oxygen order. 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.
- Potential for harm · Dcited before2025-01-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a outdated medication was removed from stock for one of one medication storage observation. ADON #1 identified 111 residents resided in the facility and 111 residents were administered medications by the nursing staff. Findings: A medication storage policy, dated 01/2024, read in part, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. On [DATE] at 11:02 a.m., a magnesium chloride with calcium bottle was observed to be expired. The best by date was 09/2024. On [DATE] at 11:03 a.m., ACMA #2 stated someone was supposed to check the expiration dates and rotate the stock. They identified the best by date to be 09/2024 and stated the medication would not be appropriate to use. On [DATE] at 11:13 a.m., CMA #3 stated they checked the medications last on [DATE]. They stated they were surprised to know that something was expired.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · D2025-01-06 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the walk in freezer was in safe operating condition. The DON identified 106 residents received services from the kitchen. Findings: On 12/31/24 at 11:20 a.m. the walk in cooler located in the kitchen was observed to have an internal temperature of 34.7 degrees. On 12/31/24 at 11:21 a.m., the walk in freezer entrance was observed inside the walk in cooler. There was an accumulation of ice buildup observed on the doorway of the freezer. While standing outside the entrance door of the freezer, light was observed from inside the freezer with the door closed as far as it would go. Ice accumulation was observed on the upper section of the freezer door all the way down the inner part of the doorframe where the door should seal. Icicles varying in size were observed on the underside of the three level green metal shelving located inside the freezer. There was a clump of ice, larger than the size of a softball, located on the middle shelf. There was ice observed covering the floor of the entrance to the freezer. The CDM stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-16 · tag F0661 — patternEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 discharge summary was completed for five (#41, 44, 99, and #115) of five sampled residents reviewed for discharge summaries. The DON identified 114 residents resided in the facility. Findings: A facility policy titled Recapitulation Summary, revised on 01/12/202, read in part, .Standard of Practice: The staff will complete a recapitulation summary per standard guidelines in order to ensure the facility communicates necessary information to the resident, continuing care provider .Procedure: Follow Discharge Process or residents discharging from the facility .The summary should be completed within 20 days of the date of discharge. 1. Res #41 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, CVA affecting non-dominant side, chronic pain, insomnia, GERD, depression, muscle spasms, and hyperlipidemia. An admission/discharge summary report, dated 01/01/24 through 02/13/24, documented the resident was discharged…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-16 · tag F0725 — failed to have enough nursing staff — patternProvide 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 record review, observation, and interview, the facility failed to provide enough staff on a 24-hour basis to meet the needs of the residents for one (#48) of six residents reviewed for ADL care. The DON identified 114 residents resided in the facility. Findings: A Staffing policy, revised 03/27/23, read in part, Policy: A facility must develop and implement staffing policies, which require staffing ratios based upon the needs of the residents .Procedure: 1. The Director of Resident Care Services will determine staffing ratios based on the level of care required by the residents . Res #48's quarterly assessment, dated 11/17/23 documented the resident's cognition was intact, required substantial assistance with most ADL's, and was always incontinent of bowel and bladder. Daily Staffing sheets, dated from 01/26/24 to 02/13/24, documented 27 of 57 shifts did not meet the staffing ratio requirements for the facility census. On 2/14/24 at 2:14 p.m., Res #48 was asked if they had any concerns regarding her care. They stated no one had been in to change their brief today. They were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-16 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow physician orders to provide diabetic residents with an HS snack and ensure snacks were served to all residents at times in accordance with resident's needs, preferences, and requests for four (#18, 26, 32, and #38) of four sampled residents reviewed for food and nutrition services. The DON identified 34 residents diagnosed with diabetes resided in the facility. Findings: A facility policy titled, Snacks and Supplements, dated 08/01/2018, read in part, .The Nutrition Services employee will prepare snacks and supplements in accordance with physician's order .1. Physician-ordered supplements (or snacks) and all-purpose snacks are prepared and available to residents three times daily .4. HS snacks will include a variety of foods to ensure each resident has an opportunity for a snack . 1. Resident #18 had diagnoses which included diabetes mellitus and protein-calorie malnutrition. A physician order, dated 03/02/22, documented to provide a daily bedtime snack. On 02/13/24 at 2:10pm., Res #18 was asked 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.
- Potential for harm · E2024-02-16 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents' call lights were in reach for five (#3, 5, 21, 50 and #64) of five sampled residents who were reviewed for call light placement. The DON identified 114 residents resided in the facility. Findings: A Call Lights: Answering policy, dated 01/19/23, read in part, .Procedure .7. When leaving the room, be sure the call light is placed within the resident's reach. 1. Res #3 had diagnoses which included dementia, overactive bladder, difficulty in walking, chronic pain, dizziness, and HTN. A quarterly assessment, dated 11/08/23, documented the resident's cognition severely impaired, always incontinent of bowel and bladder, required substantial assistance with most ADLs. On 02/14/24 at 8:10 a.m., observed the resident in bed and their call light was hanging from the wall at the end of their bed. On 02/14/24 at 1:20 p.m., observed the resident in bed and their call light was hanging from the wall at the end of their bed. On 02/15/24 at 8:06 a.m. observed the resident in bed and their call light was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-16 · tag F0620 — isolatedNot require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
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 obtain signatures by the responsible party on admissions agreements for one (#44) of one resident reviewed for admissions. The director of nursing identified 114 residents who resided in the facility. A facility policy titled, Admissions, revised 03/13/2023, read in part, .Pre- admission: .4. the director of admissions or designee will meet with the resident or the resident's agent or guardian .and will answer all questions pertaining to admission to the community .5. An acknowledgment Form, indicating that these items have been discussed with the resident/guardian, will be signed and dated by the resident/guardian and witnessed by the community representative. A copy of this signed form will be given to the resident . Findings: Res #44 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, UTI, hyponatremia, CVA, and bulimia. The facility's admission packet, at the time of the resident's admission, contained the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-16 · tag F0732 — isolatedPost 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 post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The DON identified 114 residents resided in the facility. Findings: On 02/13/23 through 02/16/23 hall 200 nurse staffing information was not posted. On 02/13/23 through 02/16/23 hall 300 nurse staffing information was not posted. On 02/13/23 through 02/16/23 hall 400 nurse staffing information was not posted. On 02/13/23 through 02/16/23 hall 500 nurse staffing information was not posted. On 02/16/24 at 3:03 p.m., the DON reported the nurse staffing information should have been posted in a prominent area daily.
- Potential for harm · Ecited before2023-11-30 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to administer medications as ordered for two (#2 and #79) of six sampled residents reviewed for medications. ADON #1 identified 105 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included HTN. Physician orders, dated 09/29/23, documented atenolol (a beta blocker) 25 mg tablet one per day. Hold if SBP less than 100, hold if DBP less than 60, hold if pulse less than 60; and losartan (an angiotensin converting enzyme inhibitor) 50 mg tablet two times per day. Hold if SBP less than 100, hold if DBP less than 60, hold if pulse less than 60. The October 2023 MAR documented atenolol was not held one out of five opportunities when the SBP was less than 100, DBP less than 60, pulse less than 60. It was documented losartan was not held three out of 12 opportunities when the SBP was less than 100, DBP less than 60, pulse less than 60. The November 2023 MAR documented losartan was not held five out of six opportunities when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-30 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident records were accurate for two (#51 and #98) of two sampled residents for accurate records. ADON #1 identified 105 residents resided in the facility. Findings: The Documentation - Clinical policy, revised 01/12/20, read in parts, .The IDT will be responsible for recording, care and treatment, observations and assessments and other appropriate entries in the resident clinical record according to professional practice guidelines . 1. Resident #98 had diagnoses which included cerebral infarction, peripheral vascular disease, dysphasia, and aphasia. A care plan intervention, dated 11/07/23, documented to monitor oral intake of food and fluid. A comprehensive MDS, dated [DATE], documented Resident #98's cognition was impaired. An ADL performance monitoring sheet, dated 11/29/23 at 11:45 a.m., documented Res #98 consumed 75 % of the lunch meal. On 11/29/23 at 12:25 p.m., Res # 98 was observed in bed sleeping with bed side table nearby. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an appointment was scheduled for a resident to see a specialist for one (#75) of one sampled resident reviewed for choices. ADON #1 identified 105 residents resided in the facility. Findings: Res #75 had diagnoses which included elevation of levels of liver transaminase levels. A quarterly resident assessment, dated 09/02/23, documented the resident's cognition was intact. A physician order, dated 08/11/23, documented liver clinic referral. The order was discontinued on 09/15/23. A physician order, dated 09/15/23, documented hepatology appointment. A physician referral response letter, dated 11/07/23, documented lab results within the last six months for a CBC, CMP, and PT/INR and imaging reports of the resident's abdomen showing the liver within the last month were required to be submitted within ten business days before an appointment could be scheduled with the hepatologist. On 11/28/23 at 9:49 a.m., Res #75 stated the SSD was supposed to make them an appointment to see a liver doctor two months ago, but they had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure neurological checks were completed after a fall with head injury for one (#35) of two sampled residents reviewed for accidents. The ADON identified 105 residents resided in the facility. Findings: Res #35 admitted to the facility on [DATE] with diagnoses which included muscle weakness and history of transient ischemic attack. An admission MDS, dated [DATE], documented Res #35 was moderately cognitively impaired and had no falls prior to admission. A nurse note, dated 11/23/23, documented Res #35 had a fall in their room and was sent to the emergency room for assessment. A hospital record, dated 11/23/23, documented Res #35 had a diagnosis of a closed head injury. A neurological check log, dated 11/23/23 through 11/26/23, documented neurological checks were not completed for 8 of 10 opportunities. On 11/28/23 at 9:56 a.m., Res #35 was observed in their room resting in bed. They stated they recently had a fall and hit their head.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 there was ongoing communication with the dialysis center and ongoing assessment of a resident after dialysis for one (#363) of one sampled resident reviewed for dialysis services. Corporate Nurse #1 identified four residents received dialysis services. Findings: The Dialysis-Hemodialysis policy, revised 02/12/20, read in part, .Documenting dialysis in the EHR . The dialysis staff and the community staff will participate in ongoing communication by completing the dialysis collection form as follows .Pre-Dialysis: Section A to be completed by the sending community license, nurse and accompany the patient to the dialysis center .Post dialysis: Community nurse to complete section B with dialysis center information. Community nurse to assess and complete section C . Place document in the appropriate section of the medical record . Res #363 had a diagnosis which included end stage renal disease. A physician order, dated 09/29/23, documented dialysis on Monday, Wednesday, and Friday. The October 2023 and November 2023…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-13 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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
5. Resident #77 had diagnoses which included non-pressure chronic ulcer of other part of left lower leg with necrosis of bone, pressure ulcer of sacral region, stage 4, and unspecified atrial fibrillation. Resident #77's quarterly assessment, dated 05/27/22, documented the resident was cognitively intact and required physical assistance for the task of bathing. A Care Plan, dated 12/12/22, documented Resident #77 preferred a bed bath for bathing. A review of the bathing records for October 2022 documented the resident had one shower on 10/17/22. There was no other documentation the resident received a shower/bath any other day in the month of October. A review of the bathing records for November 2022 documented the resident received a shower/bath on 11/08/22, 11/10/22, 11/14/22, and 11/17/22. There was no other documentation the resident had been offered/refused a shower/bath for the rest of the month of November. The facility bathing schedule sheet, undated, documented the resident was to receive a bath twice a week on Monday and Thursday. On 12/07/22 at 6:35 p.m., Resident #77 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-13 · tag F0745 — failed to provide medically-related social services — patternProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure physician ordered appointments were scheduled for two (#47 and #72) of three sampled residents reviewed for outside appointments. The Resident Census and Conditions of Residents report, dated 12/07/22, documented 107 residents resided in the facility. Findings: The facility's Service Coordination with Third Party Healthcare Providers policy, revised 01/12/20, read in part, .If health care services are performed outside a community, arrange transportation .Refer to Social Services and assist resident in coordination of service . 1. Resident #47 had diagnoses which included TIA, morbid obesity, and osteoarthritis. A Physician Order, dated 05/19/22, read in part, .Orthopedic Consult ORTHO APT . A Nurse's Note, dated 05/19/22, read in part, .New order .to see ortho for chronic back pain .appointment will be set up for after [resident's] skilled stay . On 12/12/22 at 8:38 a.m., the SSD was asked if they were responsible for scheduling appointments for the residents. They stated they were. They were asked if Resident #47…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-13 · tag F0880 — failed to prevent and control infections — patternProvide 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 interviews, the facility failed to ensure personal care was provided in a manner which prevented cross contamination for two (#1 and #301) of six sampled residents observed during incontinent care. The Resident Census and Conditions of Residents report, dated 12/07/22, documented 34 residents who were occasionally or frequently incontinent of bowel and 66 residents who were occasionally or frequently incontinent of bladder. Findings: A Hand Hygiene for Staff and Residents policy, reviewed 01/22, read in part, .Hand Hygiene is the most important component for preventing the spread of infection .Hand hygiene is done: Before .resident contact .taking part in a medical or surgical procedure .After .contact with soiled or contaminated articles .resident contact .toileting or assisting others with toileting, or after personal grooming . When hands are visibly dirty or contaminated .wash hands with either non-antimicrobial soap and water or an antimicrobial soap and water .If hands are not visibly soiled, use an alcohol-based rub for routinely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 record review and interview, the facility failed to assess a change in the resident's skin condition for one (#201) of four sampled residents reviewed for wound care. The regional nurse identified 15 residents with non-pressure ulcer wounds resided in the facility. Findings: The facility's Documentation and Measurement of Wounds policy, revised July 2018, read in part, .Wound Data Collection, treatments and evaluations are documented in the EMR/medical record .Document in the appropriate areas of the EMR/medical record on a consistent schedule. Areas include skin data collection modules, wound assessment modules, infection control modules, Care Plans, Nurses' Notes, scanned documents, and physician progress notes . Resident #201 had diagnosis which included personal history of transient ischemic attack (mini stroke). Resident #201's Daily Skilled Note, dated 01/15/22, documented the resident had open lesions on the upper back. Resident #201's Daily Skilled Note, dated 01/16/22 and 01/17/22, documented the resident had open lesions on the upper back and the services provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews, the facility failed to ensure incontinent care was provided in a manner which removed all stool from a resident for one (#1) of six sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 12/07/22, documented 34 residents who were occasionally or frequently incontinent of bowel. Findings: A PERINEAL CARE policy, revised 02/12/20, read in part, .Staff will provide cleanliness of genitalia to avoid skin breakdown and infection .Staff will perform perineal/incontinent care with each bath and after each incontinent episode . Resident #1 had diagnoses which included epilepsy and traumatic brain injury. Resident #1's Care Plan, revised 08/23/22, documented the resident was at risk for problems with elimination. It documented the resident was incontinent of bowel and bladder at times and staff were to provide pericare after each incontinent episode. Resident #1's quarterly assessment, dated 11/14/22, documented the resident was always incontinent of bowel and required extensive two person…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-13 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 timely transportation to the facility from dialysis for one (#7) of one sampled residents reviewed for dialysis. The Resident Census and Conditions of Residents report, dated 12/07/22, documented 6 residents received dialysis services outside of the building. Findings: The facility's Service Coordination with Third Party Healthcare Providers policy, revised 01/12/20, read in part, .If health care services are performed outside a community, arrange transportation .Refer to Social Services and assist resident in coordination of service . Resident #7 had diagnoses that included chronic kidney disease stage 4 and ESRD. A Physicians' Order, dated 08/31/22, documented dialysis Monday, Wednesday and Friday. Resident #7's quarterly assessment, dated 09/20/22, documented the resident was cognitively intact, required extensive and total assist with mobility, and received dialysis services. A grievance, dated 12/07/22, documented the resident was picked up from dialysis late due to emergency transportation issues. On 12/07/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to administer medications as ordered by the physician for one (#96) of six sampled resident reviewed for medication. The Resident Census and Conditions of Residents report, dated 12/07/22, documented 107 residents resided in the facility. Findings: Resident #96 had diagnoses which included non-traumatic spinal cord dysfunction and traumatic spinal cord dysfunction. Resident # 96's Physician Order, dated 10/11/22, documented the resident was to receive Morphine ER 15 milligrams one tablet every 12 hours. Order Administration Notes, dated 12/12/22 and 12/13/22, documented the facility was waiting on the morphine to be sent by the pharmacy. A Nurse's Note, dated 12/13/22, documented ADON #2 notified the physician the resident was out of Morphine ER and requested the script to be signed and sent to the pharmacy for a STAT fill. On 12/13/22 at 9:11 a.m., Resident #96 stated they did not receive their morphine pain medication on 12/12/22 at 8:00 a.m. or 8:00 p.m. CMA #1 explained to the resident the medication was ordered and as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-13 · tag F0809 — failed to serve meals on a reasonable schedule — isolatedEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure meals were served in a timely manner for one of two meal services observed. The regional nurse identified 104 residents received meals from the kitchen. Findings: An undated Mealtimes schedule documented lunch was to be served from 12:00 p.m. to 1:30 p.m. On 12/07/22 at 12:25 p.m., the RD stated some trays went out first to the halls for residents who go to dialysis or required extra time to eat or be assisted. They stated then the dining room was served and then the rest of halls trays were delivered. On 12/07/22 at 6:36 p.m., Resident #17 stated the meal service was usually slow. On 12/08/22 at 12:17 p.m., the first plate for lunch meal service was plated. On 12/08/22 at 12:31 p.m., [NAME] #1 and #2 were observed waiting on meal tickets from the floor staff. On 12/08/22 at 1:15 p.m., ADON #1 counted the remaining hall tray tickets and stated there were 40 more to be served. On 12/08/22 at 1:38 p.m., the RD stated they were making more food for the lunch meal. On 12/08/22 at 2:15 p.m., the last lunch…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-13 · tag F0925 — failed to control pests — isolatedMake 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 observation, record review and interview, the facility failed to ensure a pest free environment for two (#88 and #202) of 32 sampled residents reviewed for pest control. The Resident's Census and Conditions report, dated 12/07/22, documented 107 residents resided in the facility. Findings: A pest control report, dated 03/18/22, read in part, .Inspected for biting insects room [residents' room identified] no Activity found . 1. Resident #202 had diagnosis which included skin changes. Resident #202's admission assessment, dated 05/14/22, documented the resident's cognition was intact. Resident #202's Physician Progress Note, dated 05/27/22, documented the resident was seen and examined due to lesions on bilateral lower extremities. It documented the resident was noted to have likely insect bites to bilateral lower extremities. A pest control report, dated 05/27/22, documented this resident's room and another room on a different hall were treated for bed bugs. 2. Resident #88 had diagnosis which included hemiplegia. Resident #88's significant change assessment, dated 10/13/22,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$23,611 in federal fines across 2 penalties.
- $12,441 — penalty dated 2025-01-06
- $11,170 — penalty dated 2023-09-15
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 STONEGATE SENIOR LIVING — 24 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 1 of 5 | 2.3 | -1.3 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 23 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PF MLE SNF OPS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 11/01/2020 |
| SANCTUARY LTC, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/23/2021 |
| PRESERVATION FREEHOLD COMPANY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 09/23/2021 |
| UMB BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 09/23/2021 |
| STONEGATE SENIOR LIVING, LP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/22/2022 |
| CHANCE, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2020 |
| HARDY, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/10/2025 |
| TAYLOR, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/01/2020 |
| WHITWORTH, MONDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/21/2022 |
| CAMPBELL, SCOTT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/12/2025 |
| FISHER, JAMES | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/12/2025 |
| LANGDON, THOMAS | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/21/2025 |
| MCGEHEE, WILLIAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/21/2025 |
| LIFETIME WELLNESS, LTD. | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| MARTUS FINANCIAL SERVICES, INC. | Organization | ADP OF THE SNF | — | since 12/31/2023 |
| PHARMERICA DRUG SYSTEMS LLC | Organization | ADP OF THE SNF | — | since 08/29/2017 |
| REHAB PRO LP | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| RAJU, SENTHIL | Individual | ADP OF THE SNF | — | since 06/01/2018 |
CMS files one row per role, so the 25 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375256. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-06, 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.