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Northwest Nursing Center

2801 Northwest 61St Street, Oklahoma City, OK 73112 · For profit - Corporation · 100 certified beds · (405) 842-6601 Medicare & Medicaid certified

Call the home — (405) 842-6601 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Jul 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$10,062 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,062 in federal fines (most recent 2023-09-13)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5929 N May Ave · (405) 454-8703 · Call to confirm hours
Pharmacy
3300 NW Expressway, Suite 1D1191 · (405) 951-2345 · Call to confirm hours
Grocery
6410 N May Ave · (405) 879-9989 · Call to confirm hours
Park
Ross Park0.2 mi
2699 NW 62nd St · Typically dawn to dusk
Place of worship
2828 NW 57th St · (405) 842-5509

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 3 of 5
Long-stay residentspeople who live here 4 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 fell from 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.6%13.6%15.4%better
Long-stay residents who lose too much weight5.7%3.3%5.4%typical
Long-stay residents with a catheter left in their bladder2.0%1.9%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.9%2.8%2.0%better
Long-stay residents with depressive symptoms4.8%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 injury1.3%4.7%3.3%better
Long-stay residents whose ability to walk worsened14.7%13.7%16.1%typical
Long-stay residents on antianxiety or hypnotic medication20.5%25.7%18.9%typical
Long-stay residents given the seasonal flu vaccine86.7%94.6%95.3%typical
Long-stay residents with pressure ulcers5.7%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control15.6%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.5%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication8.5%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine50.0%74.1%79.4%worse
Short-stay residents rehospitalized after admission27.8%27.3%22.6%worse
Short-stay residents with an outpatient ER visit10.2%16.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.572.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.202.961.80better

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

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

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

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

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

0.17U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

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 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified73.1%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 worsened3.9%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

0.21
RN hours/ resident / day
1.05
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.37
Total nurse hours/ resident / day
0.32
RN hoursweekends
63.9%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 100 beds and averages 58.5 residents a day — about 58% occupied, or roughly 42 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.13 hrs/resident/day on weekends vs 3.47 on weekdays — 10% thinner on weekends. RN hours go from 0.16 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% 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

16
deficiencies at the latest standard inspection (2025-07-23)
0
at the previous standard inspection (2024-10-31)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2023-09-13 · 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 A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 01/08/23 related to the facility's failure to ensure an elopement assessment was completed on admission and a resident was free from accident hazards for a resident who had diagnoses of schizoaffective disorder and history of stimulant abuse. The facility failed to prevent Resident #102 from eloping from the facility which had the potential to result in serious injury or harm. On 09/11/23, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent accident hazards related to elopement. The past noncompliance IJ was removed effective 05/09/23 after the facility put measures in place to prevent recurrence. On 01/09/23 staff was in-serviced about the policy and procedure on elopement. The facility performed an elopement community-based drill on 03/20/23 and 03/21/23. The facility completed elopement assessments on all residents by…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2025-07-23 · 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 an accident did not occur for a resident during facility transport for 1 (#7) of 1 sampled resident reviewed for accident hazards. The administrator identified eight residents used the facility van for transportation. Findings:On 07/17/25 at 10:59 a.m., the maintenance supervisor demonstrated the process of preparing a resident for transport per wheelchair using the facility van. There were four straps to be connected to the wheelchair at all sides. An undated form titled Policy and Procedure Securing a Wheelchair For Van Transport, read in part, Safety is the top priority when transporting wheelchair users in a wheelchair van. Position the wheelchair in the van as close as possible to the safety straps bolted in the floor. Check that the wheelchair's locks are in place and that four straps with hooks are bolted on the floor, as well as the regular seat belt that goes around the person who is in the wheelchair. Put the seat belt across the individual's lap and chest and fasten it. Adjust the seat belt…

    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 · E2025-07-23 · tag F0637 — pattern
    Assess the resident when there is a significant change in condition
    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 significant change assessment had been completed when hospice services were elected for 2 (#4 and #75) of 19 sampled residents whose assessments were reviewed.The administrator identified 11 residents on hospice services.Findings: 1. A progress note, dated 03/19/25, showed Resident #75 wanted to switch hospice companies. A physician order, dated 03/21/25, showed Resident #75was ordered to be evaluated by the resident's hospice of choice. A significant change assessment, dated 05/16/25, showed Resident #75 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, had a life expectancy of less than 6 months, and the sections of the assessment had been completed on 06/02/25. On 07/23/25 at 6:00 p.m., the administrator was asked when Resident #75 had been originally admitted to hospice services. They stated they did not have an order for the first hospice Resident #75 had been admitted to, but they had elected the hospice benefit in February or March 2025 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-23 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 baseline care plan was developed within 48 hours of admission for 3 (#20, 29, and #69) of 18 sampled residents reviewed for baseline care plans.The administrator identified 62 residents resided in the facility. Findings:An undated policy titled Care Plans, read in part, To assure the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. A policy titled Baseline Care Plan, dated 08/01/24, read in part, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality .The baseline care plan will .Be developed within 48 hours of a resident's admission 1.An admission MDS, dated 02/19/25, showed Resident #20 was admitted to the facility on [DATE] with diagnoses to include depression 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-23 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure a comprehensive care plan was developed for 3 (#61, 69, and #73) of 18 sampled residents reviewed for care plans. The administrator identified 62 residents resided in the facility. Findings: 1. An admission assessment, dated 02/20/25, showed Resident #73 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of end stage renal disease. The care area assessment summary showed visual function, ADL function, urinary incontinence/indwelling catheter, psychosocial well-being, activities, falls, nutritional status, pressure ulcer, psychotropic drug use, pain, and return to the community referral were all triggered care areas from the assessment and care planning decisions had been made. The admission assessment showed the care area assessment summary and care planning decisions had been completed by the VP of reimbursement on 02/28/25. A care plan, reviewed 06/09/25, showed a care plan for falls. The care plan did not show the other triggered areas 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-23 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 range of motion was provided to residents for 3 (#2, 13, and #61) of 3 sampled residents reviewed for position and mobility.The administrator identified 12 residents had limited range of motion resided in the facility.Findings:1. On 07/15/25 at 11:57 a.m., Resident #2 was in bed and had contracted upper and lower extremities. A quarterly resident assessment, dated 06/16/25, showed Resident #2 had diagnoses which included spastic quadriplegic cerebral palsy and aphasia. The assessment showed the resident's cognition was severely impaired. The assessment showed the resident had impairment on both upper and lower extremities. The assessment showed no passive or active range of motion was perform in the seven days look back period. The assessment showed the resident was dependent on staff assistance for all activities of daily living. There was no documentation Resident #2 received range of motion services. 2. On 07/15/25 at 12:53 p.m., Resident #13 was observed in bed with right side weakness 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 · E2025-07-23 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide 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 residents who received dialysis services were assessed before and after dialysis for 1 (#7) of 1 sampled resident reviewed for dialysis.Corporate Nurse Consultant #1 identified two residents who required dialysis.Findings: An undated policy titled End-Stage Renal Disease, Care of a Resident with, read in part, Residents with end-stage renal disease [ESRD] will be cared for according to currently recognized standards of care. An annual assessment, dated 04/12/25, showed Resident #7 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, had a diagnosis of end stage renal disease, and received dialysis. A July 2025 treatment record showed the fistula for Resident #7 was monitored every shift. A care plan, reviewed 07/14/25, showed Resident #7 required dialysis and was scheduled weekly on Monday, Wednesday, and Friday at 1:30 p.m. A Dialysis Communication form, dated 07/18/25, showed vital signs had been obtained for Resident #7 by facility staff. The bottom…

    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 · E2025-07-23 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 anticoagulant monitoring was in place for a high-risk medication for 1 (#69) of 5 sampled residents reviewed for unnecessary medication. The administrator identified 62 residents resided at the facility, and 30 residents received anticoagulant therapy. Findings: An undated policy titled High Risk Medications-Anticoagulants, read in part, This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systemic approach to managing anticoagulant therapy for efficacy and safety.The resident's plan of care shall alert staff to monitor for adverse consequences. An undated order summary for Resident #69's showed diagnoses which included acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status. A physicians order, dated 03/28/25, showed Apixaban (blood thinner) 5 mg tablet two times a day. This order was discontinued 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure an annual comprehensive assessment was completed within 366 days of the previous annual comprehensive assessment for 1 (#9) of 19 sampled residents whose assessments were reviewed.The administrator identified 62 residents resided in the facility.Findings: An annual assessment, dated 11/18/24, showed Resident #9 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and a diagnosis of diabetes mellitus. The annual assessment showed it was completed on 12/13/24. An MDS 3.0 NH Final Validation Report, dated 12/13/24, showed the annual assessment for Resident #9, read in part, Assessment Completed Late: An OBRA comprehensive assessment with the Care Area Assessment [Section V] is due every year unless the resident is no longer in the facility. A prior record with an ARD [A2300] within 366 days of the submitted record could not be found. On 07/23/25 at 6:13 p.m., the administrator stated they had not had an MDS coordinator,. They stated they were utilizing the corporate MDS…

    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 · D2025-07-23 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure assessments were transmitted within 14 days of completion for 1 (#7) of 19 sampled residents whose assessments were reviewed.The administrator identified 62 residents resided in the facility. Findings: A SNF Part A discharge assessment, dated 02/26/25, showed Resident #7 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, Part A skilled services had ended on 02/26/25, and the sections of the assessment were completed on 06/02/25. An MDS 3.0 NH Final Validation Report, dated 06/05/25, showed the SNF Part A discharge assessment for Resident #7, read in part, Assessment Completed Late: Z0500B [assessment completion date] is more than 14 days after A2300 [assessment reference date] On 07/23/25 at 6:13 p.m., the administrator stated the corporate MDS coordinator had been completing assessments, but some were late due to the transition of MDS coordinators in the facility.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-23 · tag F0641 — isolated
    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 observation, record review, and interview, the facility failed to ensure a resident's assessment was accurate for 1 (#20) of 18 sampled residents reviewed for accurate assessments.The administrator identified 62 residents resided in the facility.Findings:A document titled, Transition Plan, dated 11/21/24, showed Resident #20 was discharged from an inpatient behavioral health facility on 11/21/24 with a diagnosis of schizophrenia.A Quarterly MDS, dated 05/22/25, showed Resident #20 was admitted to the facility on [DATE] with diagnoses to include depression and psychotic disorder other than schizophrenia. The MDS showed Resident #20 did not receive antipsychotic medications.A review of Resident #20's MAR for February and March 2025 showed Resident #20 received Paliperidone ER Oral Tablet Extended Release 24Hour (an atypical antipsychotic) 6 MG tablet one time daily for schizophrenia.A review of Resident #20's MAR for March, April, and May 2025 showed Resident #20 received Zyprexa Oral Tablet 5 MG (an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 accurate documentation of a diagnosis on a PASARR form for a mental health illness for 1 (#20) of 13 sampled residents reviewed for the need of a level II screening.The administrator identified 13 residents with mental illness resided in the facility.Findings:A document titled Transition Plan, dated 11/21/24, showed Resident #20 was discharged from an inpatient behavioral health facility on 11/21/24 with a diagnosis of schizophrenia.An admission MDS, dated 02/19/25, showed Resident #20 was admitted to the facility on [DATE] with diagnoses to include depression and psychotic disorder other than schizophrenia. The MDS showed Resident #20 did not receive antipsychotic medications. The MDS showed Resident #20 was not considered by the state level 2 PASARR process to have serious mental illness and/or intellectual disability or a related condition.A Psychiatric Exam, dated 02/20/25, read in part, Patient is on Paliperidone [an atypical antipsychotic]…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 21 citations
  • Potential for harm · D2025-07-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a care plan had been revised for 1 (#7) of 19 sampled residents whose care plans were reviewed.The administrator identified 62 residents resided in the facility.Findings: A Nutrition Services Note, dated 04/02/25, showed the dietician discontinued the liquid protein for Resident #7. An annual assessment, dated 04/12/25, showed Resident #7 had a BIMS score of 12, which indicated the resident was moderately impaired in cognition for daily decision making, and had a diagnosis of diabetes mellitus. A care plan, reviewed 07/14/25, showed Resident #7 had a nutritional problem and was to receive 30 milliliters of liquid protein each day. On 07/23/25 at 12:24 p.m., the MDS coordinator stated the care plan for Resident #7 had been reviewed on 07/13/25. They stated the nutrition portion of the care plan had not been revised since 09/04/24. They stated the liquid protein should not have still been on the care plan and the care plan had not been fully updated. On 07/23/25 at 12:52 p.m., corporate nurse consultant #1 stated 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 · Dcited before2025-07-23 · 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 provide bathing for 1 (#41) of 6 sampled residents reviewed for activities of daily living.The administrator identified 43 residents required assistance with bathing.Findings:An undated facility policy titled Resident Showers, read in part, Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.Resident #41's admission resident assessment, dated 05/29/25, showed the resident had impairment on one side of their upper and lower extremity. The assessment showed the resident required partial to moderate assistance with bathing with the assistance of one person. The assessment showed Resident #41's cognition was intact with a BIMS of 15.A care plan, dated 06/05/25, showed Resident #41 had diagnoses which included cerebral infarction and obesity.A Documentation Survey Report for July 2025 showed Activity itself did not occur or family and/or non facility staff provided care 100% of the time for that activity on:a. 07/05/25,b. 07/12/25, andc. 07/19/25.Resident #41…

    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 before2025-07-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure medication was administered according to physician orders for 1 (#69) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 62 residents resided at the facility. Findings: A policy titled Medication Administration, dated 05/01/24, read in part, Administer medication as ordered in accordance with manufacturer specifications .Sign MAR after administration. An undated order summary for Resident #69 showed diagnoses which included acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status. A physician's order, dated 04/19/25, showed Guaifenesin (expectorant) three times a day. A physician's order, dated 04/20/25, showed Ipratropium-Albuterol (bronchodilator to prevent bronchospasm) three times a day for wheezing and sob. A review of Resident #69's medication administration record dated 04/01/25 - through 04/30/25 showed blank boxes for:a. Guaifenesin on 04/19/25 at 8:00 a.m., 2:00 p.m., 8:00 p.m., and on 04/20/25 at 8:00 a.m.,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure infection control was maintained:a. during provision of incontinent care for 1 (#13) of 6 sampled residents reviewed for ADL care, andb. appropriate personal protective equipment was worn for a resident on enhanced barrier precautions for 2 (#7 and #13) of 18 sampled residents reviewed for infection control practices. The administrator identified 62 residents resided in the facility, 16 incontinent residents, and 12 residents on EBP. Findings: A policy titled Perineal Care, dated 05/01/24, read in part, It is the policy of this facility to provide perineal care to all incontinent residents .as needed to promote cleanliness and comfort, decrease risk of infection to the extent possible . Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate .Clean the bottom of the scrotum and the anal area .Remove gloves and discard. Perform hand hygiene. Re-apply new set of gloves. Place appropriate incontinent product under resident .Remove gloves and discard. Perform hand…

    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 · D2025-07-23 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 the influenza vaccine was offered to a resident for 1 (#4) of 5 sampled residents reviewed for immunization.The administrator identified 62 residents resided in the facility.Findings:The Influenza Vaccine policy, dated 2001, read in part, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.A care plan, revised 06/09/25, showed Resident #4 was admitted on [DATE].There was no documentation Resident #4 had been offered an influenza vaccine.On 07/23/25 at 6:14 p.m., the infection preventionist stated they had no supporting documentation Resident #4 had been offered the influenza vaccine.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0887 — isolated
    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 — 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 the COVID-19 vaccine was offered to residents for 3 (#4, 29, and #61) of 5 sampled residents reviewed for immunization.The administrator identified 62 residents resided in the facilityFindings:The Vaccination of Residents policy, dated 2001, read in part, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated.1. A care plan, revised 06/09/25, showed Resident #4 was admitted on [DATE].2. Resident #29's admission resident assessment, dated 05/23/25, showed the resident was admitted on [DATE].3. A care plan, dated 07/14/25, showed Resident #61 was admitted on [DATE].There was no documentation the residents above had been offered the COVID-19 vaccine.On 07/23/25 at 6:14 p.m., the infection preventionist stated they had no supporting documentation the residents above had been offered the COVID-19 vaccine.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-23 · 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 record review and interview, the facility failed to ensure a resident:a. received appropriate care for a dehisced surgical incision for 1 (#54) of 4 sampled residents reviewed for hospitalization; andb. had an order for hospice services for 2 (#75 and #4) of 3 sampled residents reviewed for hospiceThe administrator identified 62 residents resided in the facility and 11 residents received hospice services.Findings: 1. Resident #54's significant change resident assessment, dated 06/26/25, showed the resident had diagnoses which included unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing and limitation of activities due to disability. The assessment showed the resident had moderate cognitive impairment with a BIMS of 10. A physician progress note, dated 07/04/25, showed the resident had a long right lateral knee incision which had multiple dehisced areas. The note showed they would have the staff contact the surgeon's office to make sure they know about the dehisced areas. There was no documentation the facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure an allegation of abuse/mistreatment was reported to the appropriate licensing board in a timely manner for 5 (#23, 40, 53, 72, and #77) of 6 sampled residents reviewed for abuse.The administrator identified 62 residents resided in the facility.Findings:An ABUSE, NEGLECT, EXPLOITATION AND MISAPPROPRIATION OF PROPERTY PROHIBITION policy, dated 2022, read in part, The Health Care Center establishes and implements mechanisms for reporting, investigating, and monitoring the abuse, neglect and misappropriation of property prohibition.1. An annual resident assessment, dated 05/23/25, showed Resident #23 had diagnoses which included weakness and morbid severe obesity due to excess calories. The assessment showed the resident's cognition was intact with a BIMS of 15. 2. An annual resident assessment, dated 06/04/25, showed Resident #40 had diagnoses which included unspecified hearing loss, unspecified ear and repeated falls. The assessment showed the resident had severe cognitive impairment with a BIMS of 00. 3. An annual…

    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 · D2025-07-23 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 notification of a bed hold was provided upon transfer for 1 (#73) of 4 sampled residents who were reviewed for hospitalization.The administrator identified 62 residents resided in the facility.Findings:The admission assessment, dated 02/20/25, showed Resident #73 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of end stage renal disease. An entry under the Census section of the electronic clinical record, dated 04/05/25 through 06/15/25, showed Resident #73 was a long-term care resident. A physician order, dated 06/15/25, showed Resident #73 was transferred to the emergency room to be evaluated and treated. A progress note, dated 06/15/25, did not show notification of a bed hold had been provided. On 07/22/25 at 2:46 p.m., LPN #1 stated the administrator or social services director provided bed hold information when a resident was transferred to the hospital. On 07/23/25 at 8:30 a.m., LPN #4 stated they did not know who provided notification…

    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 before2024-04-04 · 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 record review and interview, the facility failed to ensure: a. meal consumption percentages were documented on a resident who experienced weight loss for two (#3 and #7); and b. weights were documented on a resident who experienced weight loss for three (#2, 3, and #5) of three sampled residents reviewed for weight loss. The Administrator identified 47 residents resided in the facility. Findings: The Weight Assessment and Intervention policy, revised 09/08, read in part, .The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter .If no weight concerns are noted at this point, weights will be measured monthly thereafter . The Frequency of Meal policy, revised 07/17, read in part, .Each resident shall receive at least three meals daily . 1. Resident #2 had diagnoses which included dysphagia and cerebral infarction. A physician's order, dated 11/06/23, documented weekly weights every day shift, every Monday. The November 2023 TAR documented blanks for Resident #2's weight on the 6th, 13th, and 20th. The December 2023 TAR…

    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 · D2024-04-04 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to notify the physician in a timely manner regarding abnormal lab results for one (#8) of eight sampled residents reviewed for weight loss. The Administrator identified 47 residents resided in the facility. Findings: The Test Results policy, revised 04/07, read in part, .Should the test results be provided to the facility, the Attending Physician shall be promptly notified of the results .The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results . A physician's order, dated 03/22/24, documented to check bmp a week from today. A laboratory report, dated 03/29/24, documented a high lab result for potassium. There was no documentation the physician was notified of the abnormal lab result. On 04/02/24 at 2:13 p.m., the DON stated the physician should be notified on all abnormal lab results. They reviewed Resident #8's electronic health record. They could not locate a physician notification for the lab result reported on 03/29/24. On 04/03/24…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-13 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to: a. assess a resident's cognition, mood, and pain on a quarterly resident assessment for one (#1); b. assess a resident's cognition and mood on an admission resident assessment for one (#1); and c. assess a resident's pain on a significant change resident assessment for one (#25) of 22 sampled residents reviewed for resident assessments. The Census and Conditions of Residents report, dated 09/06/23, documented 51 residents resided in the facility. Findings: 1. Resident #1 had diagnoses which included altered mental status, spastic quadriplegic cerebral palsy, and epilepsy. An admission Resident Assessment, dated 09/16/22, documented dash marks for the cognitive patterns section BIMS for the resident interview section and dash marks for the staff assessment for mental status section. It documented a 99 (unable to complete interview) for the resident mood interview and dash marks for the staff assessment of resident mood section. A Quarterly Resident Assessment, dated 06/19/23, documented no as the response to should a BIMS…

    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 · Ecited before2023-09-13 · 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 and interview, the facility failed to ensure a resident received a bath/shower as scheduled for one (#103) of six sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 09/06/23 documented 10 residents were independent, 21 residents required one or two staff members assistance, and 20 residents were dependent on staff for the task of bathing. Findings: A Shower/Tub Bath policy, revised 10/10, read in part, .The following information should be recorded on the resident's ADL record and/or in the resident's medical record .The date and time the shower/tub bath was performed .The name and title of the individual(s) who assisted the resident with the shower/tub bath .If the resident refused the shower/tub bath, the reason(s) why and the intervention taken .Notify the supervisor if the resident refuses the shower/tub bath . Resident #103 admitted to the facility on [DATE] and had diagnoses which included unspecified protein-calorie malnutrition,…

    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 before2023-09-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor nutritional intake for one (#103) of three sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 51 residents resided in the facility. It documented 29 independent residents, 14 residents who required one or two staff members, and eight resident who were dependent on staff for the task of eating. Findings: A Resident Nutrition Services policy, revised 07/17, read in part, .Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .Nursing personnel will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems . Resident #103 admitted to the facility on [DATE] and had diagnoses which included unspecified protein-calorie malnutrition, vitamin D deficiency, iron deficiency anemia, cachexia, and gangrene and necrosis of lung. A…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-13 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to: a. administer medication as ordered by the physician for one (#25) of five sampled residents reviewed for unnecessary medications; and b. ensure expired medications were removed from circulation for two of two medication carts observed during the medication pass and storage observation. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 51 residents resided in the facility. Findings: An Administering Medications policy, revised 12/12, read in part, .Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered within [one] hour of the prescribed time, unless otherwise specified .The expiration/beyond use date on the medication label must be checked prior to administering . 1. Resident #25 had diagnoses which included schizoaffective disorder, bipolar type, depression, and hyperlipidemia. A Physician Order, dated 06/15/22, documented atorvastatin calcium tablet 80 mg give one tablet by mouth at bedtime related 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-13 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure a PRN order which included an antipsychotic medication and an antianxiety medication was reassessed after 14 days and the duration of use was identified for one (#102) of fourteen sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 51 residents resided in the facility and 33 residents were receiving psychoactive medications. Findings: An Antipsychotic Medication Use policy, revised 10/16, read in part, .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review .Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record .The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure a resident's call light was within reach for one (#13) of 24 sampled residents observed for call lights in reach. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 51 residents resided in the facility. Findings: The facility's Answering the Call Light policy, revised 10/10, read in part, .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Resident #13 had diagnoses which included abnormalities of gait and mobility, limitation of activities due to disability, fracture of left femur, and repeated falls. Resident #13's quarterly resident assessment, dated 09/05/23, documented the resident had moderately impaired cognition and required extensive one person physical assistance with bed mobility and toilet use. The quarterly resident assessment documented resident had a functional limitation in range of motion related to impairment on one side for the lower extremity. A care plan, dated 09/08/23, documented Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-13 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to complete a pre-employment background check for one (CNA #5) of five employee records reviewed for background checks. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 51 residents resided in the facility. The administrator reported there were 54 employees. Findings: A facility policy, titled Resident Abuse, dated 09/12, documented .persons applying for employment with the facility will be screened for a history of abuse, neglect, or mistreating residents to include: a. criminal background check, and b. abuse check with appropriate licensing board and registries, prior to hire . An application form, signed by CNA #5, dated 01/23/23, documented .I acknowledge that a computerized criminal history check will be performed by accessing the State Department of Public Safety secure website if I am offered a job with this company . CNA #5 was hired on 03/08/23 and had no documentation a criminal background check had been completed on hire. A State reportable, dated 03/24/23, documented an abuse…

    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 before2023-09-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to fully develop a comprehensive care plan for one (#25) of 22 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 51 residents resided in the facility and seven residents received antipsychotic medications. Findings: A Care Plans, Comprehensive Person-Centered policy, revised 12/16, read in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #25 had diagnoses which included neuralgia and neuritis, cognitive communication deficit, and schizoaffective disorder, bipolar type. A Physician Order, dated 10/26/22, documented Zyprexa (an antipsychotic medication) 7.5 mg give one tablet by mouth at bedtime related to schizoaffective disorder. A Significant Change Resident Assessment, dated 04/19/23, documented schizophrenia under active diagnoses and the resident received an antipsychotic…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to complete a wandering assessment accurately for one (#102) of three sampled residents reviewed for elopement. The DON identified three residents at risk for elopement resided in the facility. Findings: A Charting and Documentation policy, revised 07/17, read in part, .Documentation in the medical record will be objective .complete, and accurate . Resident #102 had diagnoses which included schizoaffective disorder, other stimulant abuse in remission, and anxiety disorder unspecified. A Physician Order, dated 10/12/22, documented lorazepam 0.5 mg give one tablet by mouth every eight hours as needed for anxiety for 14 days. A Physician Order, dated 10/12/22, documented Norco tablet 10-325 mg give one tablet by mouth every six hours as needed for pain. Resident #102's Wandering Risk Assessment, dated 10/12/22, documented an admission date of 10/12/22. The recent experiences section did not have admission within the last month marked. The mobility section had nothing marked. The medication section had nothing marked. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-13 · tag F0908 — failed to keep essential equipment working — isolated
    Keep 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 remove a moderate amount of lint for two of two dryers observed in the laundry room for lint. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 51 residents resided in the facility. Findings: An undated and untitled facility policy, read in part, .Confirm that the lint is removed from the stack and inside the dryer. It is a fire hazard and a code violation if this is not maintained .Lint catchers should be cleaned AFTER EACH LOAD . On 09/08/23 at 9:31 a.m., during laundry room observations, the Housekeeping Supervisor was asked how often they cleaned dryer lint. They stated three times a day. On 09/08/23 at 9:32 a.m., a moderate amount of lint was observed on the floor in the lint compartment in dryer two located at the end of the room. The Housekeeping Supervisor separated the lint and squeezed in their right hand to form two hands full. They stated they personally ran two loads that morning. On 09/08/23 at 9:34 a.m., the Housekeeping Supervisor pulled out a thick sheet of lint from dryer…

    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

$10,062 in federal fines across 1 penalty.

  • $10,062 — penalty dated 2023-09-13

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

Part of a chain

This home belongs to SOUTHWEST LTC — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 2 of 51.3+0.7 vs chain
Quality measures 3 of 52.4+0.6 vs chain
The other 9 homes this chain runs (chain average 2.4★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
QUALITY CARE GIVERS INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
RONALD R PAYNE PCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
SOUTHWEST LTC, LTDOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
BARONET, RODIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
BRASHIER, CRAIGIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/27/2015
HINES, BARRYIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2016
PAYNE, RONALDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/01/2016
SOUTHWEST LTC MANAGEMENT SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2016

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

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

Follow the money — this home’s finances

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

$4.6M
Net patient revenuemost recent cost report
-2.0%
Operating marginrevenue minus expenses
$473K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 91%Medicare 2%Other / private 7%

About 91% 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 $473K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$258per resident / day
operating cost
$7,846per month
≈ monthly operating cost
$253per 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 375520. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, 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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