Park Place Healthcare and Rehab
1530 NE Grand Blvd, Oklahoma City, OK 73117 · For profit - Limited Liability company · 106 certified beds · (405) 768-1155 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it’s on the federal Special Focus watch list for a persistent pattern of problems
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $131,280 in federal fines (most recent 2026-02-18)
- nursing-staff turnover (88%) 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 | Not rated — CMS suppresses ratings for Special Focus Facilities |
| StaffingFrom payroll records (PBJ) | Not rated — CMS suppresses ratings for Special Focus Facilities |
| Quality measuresSelf-reported by the facility | Not rated — CMS suppresses ratings for Special Focus Facilities |
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 | Not rated — CMS suppresses ratings for Special Focus Facilities |
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.
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 | 14.5% | 13.6% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.0% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.5% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.6% | 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 | 4.2% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.1% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.1% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 82.7% | 94.6% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 10.1% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.6% | 17.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.0% | 17.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.8% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 25.5% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.8% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 4.35 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.75 | 2.96 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | not 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 SNF | 11.4%CMS range 7.4–16.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 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 | not 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 SNFs | 0.83 | 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 106 beds and averages 63.9 residents a day — about 60% 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 4.14 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 is at or above 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 2.91 hrs/resident/day on weekends vs 4.64 on weekdays — 37% thinner on weekends — a notable drop. RN hours go from 0.25 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 88% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
35 citations, most serious first. The 15 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · J2025-08-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 08/13/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure supervision was provided to a resident who smoked and used oxygen that resulted in Resident #20 igniting themselves and received second degree burns to their face.On 08/13/25 at 5:09 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 08/13/25 at 5:23 p.m., the administrator and the DON were notified of the IJ situation and the IJ template was provided.On 08/14/25 at 11:40 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Incident: Resident was smoking while wearing oxygen and accidentally ignited [themself], resulting in burn injuries and immediate life-threatening risk.1. Immediate Action Taken- Oxygen was removed from the resident's vicinity and turned off to eliminate fuel source. Staff responded immediately, extinguishing the fire, and activated emergency medical response, first aid was provided at the facility prior to transport.…
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 · Jcited before2025-06-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
On 05/28/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from verbal abuse and failure to implement interventions to protect residents from physical abuse. An admission resident assessment, dated 12/18/24, showed Resident #3's cognition was intact (BIMS 15). A quarterly resident assessment, dated 01/15/25, showed Resident #5's cognition was intact (BIMS 15). A quarterly resident assessment, dated 01/25/25, showed Resident #4's cognition was intact (BIMS 13). A facility reported incident, dated 02/28/25, showed an allegation of abuse/mistreatment involving Resident #3, Resident #4, and Resident #5. The reported incident showed at approximately 6:00 p.m., the residents were outside smoking when an alleged altercation involving threats of physical harm occurred between residents. The reported incident showed Resident #3 made verbal threats of physical harm to Resident #5. Resident #4 became upset and allegedly made threats of physical harm to Resident #3. Residents #3 and #4 were immediately separated 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.
- Actual harm · G2026-02-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 ensure:a. care plan interventions were implemented to prevent skin breakdown, andb. a resident with wounds received appropriate treatment for 1 (#26) of 3 sampled residents reviewed for pressure ulcers and skin conditions.The wound care nurse identified 12 residents had wounds in the facility. Findings:On 02/12/26 at 10:40 a.m., Resident #26 was observed with three open areas to their coccyx and buttocks during an incontinent care observation.On 02/12/26 at 10:48 a.m., CNA #1 was observed to apply vitamin A&D ointment to Resident #26's wounds.On 02/13/26 at 11:11 a.m., Resident #26 was observed lying on their back on a regular mattress.On 02/17/26 at 9:39 a.m., Resident #26 was observed lying in bed. They had a navy-blue pressure relieving mattress on their bed.An undated facility SKIN MANAGEMENT POLICY, read in part, Any resident with pressure sores will receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing based upon the resident's clinical…
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.
- Actual harm · Gcited before2026-02-18 · 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 ensure pain medication was administered as prescribed for 1 (#48) of 3 sampled residents reviewed for pain management.The administrator identified 63 residents resided in the facility. Findings: A policy titled Medication Administration, dated 04/2019, read in part, Medications are administered in accordance with prescriber orders. A policy titled Pain Assessment and Management, dated 03/2020, read in part, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management. A care plan for Resident #48, dated 10/10/25, showed the resident had generalized pain. The care plan showed an intervention for pain management was to administer analgesic medications as ordered by the physician. A physician's order for Resident #48, dated 10/10/25, showed the resident was prescribed oxycodone 5 mg (an opioid analgesic) one every six hours as needed for pain. 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.
- Actual harm · Gcited before2025-08-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 was free from abuse for 1 (#8) of 3 sampled residents reviewed for abuse.Findings:On 08/11/25 at 10:10 a.m., Resident #8 was observed sitting in a wheelchair in their room. The resident had a knot and bruising on the right side of their forehead. On 08/11/25 at 11:00 a.m., Resident #4 was observed lying in their bed with their eyes closed. On 08/11/25 at 12:10 p.m., Resident #4 was observed in the dining room with a one-on-one sitter. On 08/12/25 at 9:13 a.m., Resident #4 was observed lying in their bed with their eyes closed. An annual assessment, dated 05/30/25, showed Resident #4 was admitted to the facility on [DATE] with diagnoses to include dementia with agitation, Alzheimer's disease, and major depressive disorder. The assessment showed Resident #4 had a BIMS of 15, which indicated Resident #4 was cognitively intact. An annual, dated 06/03/25, showed Resident #8 was admitted to the facility on [DATE] 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 · F2026-02-18 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
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 the direct care staffing hours on the Quality of Care report was accurately reported to CMS during the months of 12/2025 through 01/2026. The administrator identified 63 residents resided in the facility.Findings: The Quality of Care report for the month of December 2025 showed the following was reported to CMS for direct care staffing hours for the 3 p.m. to 11 p.m. shift:a. 12/20/26, a census of 62 and 52.32 direct care staffing hours,b. 12/24/26, a census of 63 and 37.40 direct care staffing hours,c. 12/27/26, a census of 63 and 61.18 direct care staffing hours, andd. 12/28/26, a census of 61 and 61.00 direct care staffing hours. The facility payroll detail report for the month of December 2025 showed the facility had the following for the 3 p.m. to 11 p.m. shift:a. 12/20/26, 91.51 direct care staffing hours,b. 12/24/26, 63.27 direct care staffing hours,c. 12/27/26, 86.99 direct care staffing hours and,d. 12/28/26, 98.69 direct care staffing hours. The Quality of Care report for the month of January 2026 showed…
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 · E2026-02-18 · tag F0580 — failed to tell family and doctor about changes — patternImmediately 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 ensure the physician was notified when a resident's blood sugar was above 350 for 1 (#2) of 2 sampled residents reviewed for insulin.The administrator identified 63 residents resided in the facility. Findings: A Physician Notification for Resident Change in Condition, policy undated, read in part, The licensed nurse assigned to the resident is responsible for notification of and communication to the medical staff regarding significant changes.Changes in the condition of the resident are determined by assessments utilizing parameters defined by physician orders/instructions. Document in the medical record the date, time and name of each physician notified, actions taken and/or resident's response to treatment. A physician's order for Resident #2, dated 12/31/25, showed Humalog (an insulin medication) 100 unit per milliliter, inject as per sliding scale, for blood sugar level of 350 to 400, give 10 units and notify medical doctor, subcutaneously before meals related to type two diabetes mellitus with unspecified…
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 · E2026-02-18 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to comprehensively assess a resident's physical condition and needs for 1 (#10) of 18 sampled residents reviewed for comprehensive assessments.The administrator identified 63 residents resided in the facility. Findings:On 02/11/26 at 8:48 a.m., Resident #10's left hand was observed to be contracted and completely closed into a fist. There were no therapeutic devices in their left hand. Resident #10's left arm was observed to not raise above shoulder height. A policy titled Resident Assessments, dated 11/2019, showed appropriate resident assessments were to be completed.A Physician's Progress Note for Resident #10, dated 11/14/25, showed the resident had left sided weakness. An admission Assessment for Resident #10, dated 11/23/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included renal failure and heart failure. The assessment showed Resident #10 had no impairment to their upper extremities. 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 · E2026-02-18 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan:a. included interventions for limited range of motion for 1 (#10) of 3 sampled resident reviewed for limited range of motion,b. was implemented for offering a meal replacement supplement for 1 (#48) of 3 sampled residents reviewed for nutrition, andc. included the use of a mechanical lift for transfer for 1 (#3) of 5 sampled residents reviewed for accidents.The administrator identified 63 residents resided in the facility and the DON identified six residents used a mechanical lift for transfers. Findings: A policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, 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.The comprehensive person-centered care plan will: describe the services that are furnished or attain or maintain…
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 before2026-02-18 · 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 ensure:a. dirty linen was not placed on the floor for 1 (#41),b. soiled wipes and a soiled brief were not placed on the bed for 1 (#16),c. gloves were changed appropriately during incontinent care for 3 (#16, 40 and #41) of 4 sampled residents reviewed for activities of daily living, andd. staff worn a gown during incontinent care for 1 (#40) of 4 sampled residents reviewed for EBP.The DON identified 40 residents required assistance with incontinent care and 14 residents had EBP precautions. Findings: 1. On 02/12/26 at 5:46 a.m., CNA #5 was observed to don gloves to perform incontinent care on Resident #41. On 02/12/26 at 5:47 a.m., CNA #5 was observed to open a brief, set it on Resident #41's bedside table, remove the front of the resident's brief and assist them to turn to their left side. Fecal matter was observed on the resident's brief. CNA #5 cleaned the resident with wipes and discarded the dirty brief in the trash bag. With 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 · D2026-02-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure range of motion exercises and equipment for a contracture to maintain or improve mobility for 1 (#10) of 2 sampled residents reviewed for range of motion and mobility.The DON identified two residents had limited range of motion. Findings:On 02/11/26 at 8:48 a.m., Resident #10's left hand was observed to be contracted and completely closed into a fist. There were no therapeutic devices in their left hand. Resident #10's left arm was observed to not raise above shoulder height. A policy titled Restorative Nursing Services, dated 07/2017, read in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence.A physician's progress note for Resident #10, dated 11/14/25, showed the resident had left sided weakness. An admission assessment for Resident #10, dated 11/23/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included renal failure and heart…
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 · D2026-02-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure weight loss was unavoidable by providing meal replacement supplements for 1 (#48) of 3 sampled residents reviewed for nutrition.The administrator identified 63 residents resided in the facility. Findings:On 02/11/26 at 9:16 a.m., Resident #48 was observed lying in bed with their eyes closed. A breakfast tray was untouched sitting on their walker seat.A care plan for Resident #48, dated 10/10/25, showed the resident had a nutritional problem or potential nutritional problem related to protein calorie malnutrition. The intervention was for staff to offer Resident #48 a meal replacement supplement if 50% or less of their meal was consumed.An undated weight log for Resident #48 showed on 12/05/25, the resident weighed 170 pounds.An admission assessment for Resident #48, dated 12/20/25, showed the resident had diagnoses which included pancytopenia (a serious blood disorder characterized by dangerously low red blood cells, white blood cells, and platelets), renal insufficiency, and cirrhosis of the liver.…
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 · D2026-02-18 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to accurately complete a weekly skin assessment for 1 (#26) of 3 sampled residents reviewed for pressure ulcers and skin conditions.The wound care nurse identified 12 residents had wounds in the facility. Findings:On 02/12/26 at 10:40 a.m., Resident #26 was observed with three open areas to their coccyx and buttocks during an incontinent care observation.A physician order for Resident #26, dated 01/23/26, showed weekly skin assessment every Thursday evening night shift.An admission assessment for Resident #26, dated 01/29/26, showed the resident had diagnoses which included unspecified fracture of sacrum and abnormalities of gait and mobility. The assessment showed the resident's cognition was intact with a BIMS score of 15. The assessment showed the resident was admitted on [DATE]. A Skin Assessment by Charge Nurse for Resident #26, dated 02/12/26 at 10:58 p.m., showed the resident had no open area and their coccyx was reddened.A skin…
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 · D2026-02-18 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
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 provided with necessary behavioral health care and services for 1 (#10) of 3 sampled residents reviewed for behavioral health care needs.The administrator identified 63 residents resided in the facility. Findings: On 02/11/26 at 8:47 a.m., Resident #10 was observed to be tearful in their room. A physician's order for Resident #10, dated 11/11/25, showed the resident was to receive a psychiatric consultation for mental health needs if criteria was met as needed. An admission assessment for Resident #10, dated 11/23/25, showed the resident had a diagnosis of depression. The assessment showed it was very important for them to participate in activities. The assessment showed no behaviors and their depression screening showed no concerns. The assessment showed Resident #10 had a BIMS of 14, which indicated they were cognitively intact. A physician's order for Resident 310, dated 12/20/25, showed the resident was prescribed fluoxetine 20 mg (an anti-depressant medication) once daily for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-18 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a medication error rate was less than five percent for 2 (#53 and #56) of 4 sampled residents observed during medication pass. The facility's medication error rate was 7.41%.The administrator identified 63 residents resided in the facility. Findings:1. On 02/12/26 at 8:03 a.m., CMA #1 was observed to administer one tablet of vitamin D3 25 mcg to Resident #56.An Administering Medications policy, dated 04/2019, read in part, Medications are administered in a safe and timely manner, and as prescribe.A physician's order for Resident #56, dated 07/19/23, showed vitamin D3 50 mcg, give one tablet by mouth in the morning for supplement.On 02/12/26 at 11:29 a.m., CMA #1 stated Resident #56 was supposed to receive vitamin D3 50 mcg. They stated they should have given the resident two tablets of the house stock vitamin D3 25 mcg to equal 50 mcg.On 02/12/26 at 11:31 a.m., CMA #1 stated they did not follow the physician's order.2. On 02/12/26 at 8:37 a.m., CMA #2 was observed to administer one tablet of senna (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.
Show the remaining 20 citations
- Potential for harm · D2026-02-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 observation, record review, and interview, the facility failed to ensure a weekly skin assessment was accurately documented for 1 (#26) of 3 sampled residents reviewed for pressure ulcers and skin conditions.The wound care nurse identified 12 residents had wounds in the facility. Findings:On 02/12/26 at 10:40 a.m., Resident #26 was observed with three open areas to their coccyx and buttocks during an incontinent care observation.A Charting and Documentation policy, revised 07/2017, read in part, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.A physician's order for Resident #26, dated 01/23/26, showed weekly skin assessment every Thursday evening night shift.An admission assessment for Resident #26, dated 01/29/26, showed the resident had diagnoses which included unspecified fracture of sacrum and abnormalities of gait and mobility. The assessment showed the resident's cognition was intact with a BIMS score of 15.A Skin Assessment by Charge Nurse for Resident #26, dated 02/12/26 at 10:58 p.m., showed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-10 · 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 ensure medications were administered according to the physician orders for 1 (#8) of 3 residents sampled for medication administration.The administrator identified 55 residents resided in the facility.Findings:An Administering Medications policy, revised April 2019, read in part, Medications are administered in a safe and timely manner, and as prescribed.The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.A physicians' order, dated 03/15/25, showed atorvastatin calcium tablet (statin) 40 mg, give one tablet at bedtime.A physicians' order, dated 03/15/25, showed gabapentin capsule (anti-convulsant) 300 mg, give one capsule three times a day.A physicians' order, dated 05/06/25, showed carvedilol tablet (beta blocker) 3.125 mg, give two times a day.A physicians' order, dated 05/27/25, showed Zyprexa tablet (anti-psychotic) 10 mg, give one tablet at bedtime.A physicians' order, dated 06/24/25, showed buspirone HCI…
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 · F2025-08-18 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure the staff informed residents who attended the resident council meetings were informed of where past survey results were located in the facility. Findings:A review of the resident council meeting minutes from January 2025 through July 2025 showed no education to residents regarding the location of past facility survey results.On 08/12/25 at 9:59 a.m., the residents gathered for a resident council interview were asked if they knew where the past facility survey results were located without having to ask staff. The residents stated, No, in unison and shook their heads indicating no.On 08/18/25 at 11:07 a.m., the social services director, who helped organize resident council meetings, was asked how it was communicated to the residents where the past survey results were located. They stated, I don't know that it is communicated. They've never asked. The social services director was asked if they had ever made residents aware of where the results were located. They stated, No.
- Potential for harm · F2025-08-18 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure food served to the residents from the kitchen was palatable.The ADON identified 50 residents received nutrition from the kitchen.Findings:A lunch menu for 08/11/25 showed the residents would be served beef teriyaki, white rice, sugar snapped peas, choice of roll, and lemon bars.On 08/11/25 at 12:46 p.m., residents were observed being served a beef steak patty with white gravy instead of beef teriyaki in the dining room.On 08/11/25 12:47 p.m., a resident not included in the survey sample was served their plate and was overheard stating to their table mate, This is one of those days I wish I had money to Door Dash food.On 08/11/25 at 12:52 p.m., Resident #28 was observed having difficulty cutting the beef patty and pushed their plate away.On 08/11/25 12:59 p.m., Resident #4 stated to their one-on-one sitter they can't cut the meat. Resident #4's one-on-one sitter was then observed cutting Resident #4's beef patty.On 08/11/25 at 1:04 p.m., Resident #8 was observed to have eaten 25% of their lunch plate. On 08/11/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-18 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
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 inform residents and/or their representatives of the risk, benefits, and alternative treatment options for psychotropic medications for 5 (#4, 7, 28, 33, and #34) of 5 sampled residents whose clinical records were reviewed for unnecessary medications. The ADON identified 14 residents received psychotropic medications.Findings: An undated facility policy titled, Use of Psychotropic Medication(s), read in part, Prior to increasing or initiating a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication. 1. An undated transfer/discharge report showed Resident #28 had diagnoses which included adjustment disorder with anxiety depressive episodes, psychosis, schizoaffective disorder, and conversion disorder with seizures. A physician order, dated 04/04/25, showed Resident #28 received bupropion (an antidepressant medication) 150mg tablet daily for depression. 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.
- Potential for harm · E2025-08-18 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure:a. a PRN psychotropic medication was limited to 14 days for 1 (#3) of 5 sampled residents reviewed for PRN medications, andb. psychotropic medications were discontinued per orders for 2 (#28 and #34) of 5 sampled residents reviewed for psychotropic medications.The ADON identified 14 residents in the facility received psychotropic medications.Findings:1. An undated transfer/discharge report showed Resident #28 had diagnoses which included adjustment disorder with anxiety depressive episodes, psychosis, schizoaffective disorder, and conversion disorder with seizures. A physician order, dated 04/04/25, showed the Resident #28 received bupropion (an antidepressant medication) 150mg tablet daily for depression. A physician order, dated 05/01/25, showed the Resident #28 received trazodone (an antidepressant medication) 150mg at bedtime for depressive episodes. A quarterly assessment, dated 05/25/25, showed Resident #28 had a BIMS of 15 and 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 · D2025-08-18 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to maintain confidentiality of resident records for 1 observation during medication administration observation. The administrator identified 53 residents resided in the facility. Findings:On 08/18/25 at 11:44 a.m., and observation of an unattended medication cart in the hallway of hall 200 with the laptop opened, unlocked, and showed resident names.An undated policy titled Confidentiality of Personal and Medical Records, read in part, This facility honors the resident's right to secure and confidential personal and medical records .Keep Confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative.On 08/18/25 at 11:45 a.m., CMA #4 was asked what the policy and procedure was for ensuring the confidentiality of resident records. They stated, Should have locked it, that's my fault.On 08/18/25 at 11:50 a.m., 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 · D2025-08-18 · 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 observation, record review, and interview, the facility failed to accurately code MDS assessment data for 2 (#7 and #45) of 22 residents whose MDS assessments were reviewed.Findings: 1.An annual assessment, dated 06/03/25, showed Resident #7 was admitted to the facility on [DATE] with diagnoses to include cerebrovascular accident and muscle wasting and atrophy. The MDS assessment showed Resident #7 required substantial/maximal assistance with eating, meaning the staff lifts or holds trunk or limbs and provides more than half the effort. A Care Plan Report, dated 06/15/25, showed Resident #7 required set up, clean up and supervision assistance by one staff to eat. On 08/14/25 at 10:20 a.m., CNA #1 was asked what was Resident #7's eating and drinking ability. They stated, [They] are able to eat and drink with [their] left hand. CNA #1 was asked if Resident #7 required help with eating or drinking. They stated, Just set up. On 08/14/25 at 10:29 a.m., LPN #2 was asked what help Resident #7 required for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure:a. a physician's order for oxygen administration was followed for 1 (#45); andb. a resident had an order for the use of oxygen for 1 (#24) of 4 sampled residents reviewed for respiratory care.The administrator identified 4 residents on continuous oxygen use in the facility.Findings:1. On 08/11/25 at 3:28 p.m., Resident #45 was observed to be on 4.5 liters of oxygen via nasal canula.On 08/12/25 at 12:06 p.m., Resident #45 was observed to be on 4.5 liters of oxygen via nasal canula.An undated facility policy Oxygen Administration, read in part, Oxygen is administered under orders of a physician.A physician's order, dated 04/01/25, showed oxygen 2 liters via nasal canula every shift related to unspecified chronic obstructive pulmonary disease.Resident #45's significant change resident assessment, dated 05/27/25, showed the resident had diagnoses which included unspecified chronic obstructive pulmonary disease and unspecified heart…
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 before2025-08-18 · 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, and interview, the facility failed to ensure expired medications were removed from stock for 1 of 1 medication storage room observation. The administrator identified 53 residents resided in the facility.Findings: An undated policy titled Handling and Disposal of Expired Medications, read in part, All medications maintained in the facility must be checked regularly for expiration dates. Expired or unused medications will be removed from active stock immediately, stored securely, and disposed of according to applicable regulations. On 08/18/25 at 8:51 a.m., the medication room was observed with CMA #1. There was expired medication in the refrigerator in the back of the medication room that faces the door to the room. Inside was expired medication for Resident #34 as follows: a. 3 Onelax (constipation) suppositories 10mg. Expiration date 12/17/24. b. 5 Acetaminophen (pain reliever) suppositories 650mg. Expiration date 12/17/24. On 08/18/25 at 8:52 a.m., CMA #1 stated night shift goes through the medication room to check for expired medications, but not sure how…
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 before2025-08-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure neutropenic precautions were followed for 1 (#39) of 1 sampled resident reviewed for neutropenic precautions.Findings:A Significant Change Assessment, dated 06/19/25, showed Resident #39 was admitted to the facility on [DATE] with diagnoses to include anemia and other pancytopenia (a disorder causing low levels of all three major blood cell types which increases risk of infection). On 08/11/25 at 3:41 p.m., a sign on Resident #39's closed door showed they were under neutropenic precaution (guidelines to protect individuals with pancytopenia from infection). This sign showed no live plants. Upon entering the resident's room, there were three live plants observed on Resident #39's windowsill. On 08/12/25 at 8:31 a.m., CNA #1 was observed wearing a mask entering Resident #39's room.On 08/18/25 at 10:07 a.m., LPN #1 was asked what neutropenic precautions needed to be taken for Resident #39. They stated, Wear a mask, no plants or fresh…
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 · D2025-06-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to report an allegation of abuse to local law enforcement for 3 (#3, 4 and #5) of 5 sampled residents reviewed for abuse. The DON and the regional clinical director identified 51 residents resided in the facility. Findings: An abuse, neglect, and exploitation policy, dated 2025, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Law enforcement is the full range of potential responders to elder abuse, neglect, and exploitation including: police .Establish policies and procedures to investigate any such allegation .Reporting of all alleged violation to the Administrator, state agency, adult protective services, and to all other required agencies (e.g. law enforcement when applicable). A facility reported incident, dated 02/28/25, showed an allegation of abuse/mistreatment involving Resident #3,…
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 · D2025-06-02 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to update a residents care plan after abusive behaviors were observed for two (#3 and #4) of 5 sampled residents reviewed for abuse. The DON and the regional clinical director identified 51 residents resided in the facility. Findings: An abuse, neglect, and exploitation policy, dated 2025, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Establish policies and procedures to investigate any such allegation .Revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse .Whether an analysis was conducted as to why the situation occurred .Risk factors that contributed to the abuse (e.g., history of aggressive behaviors, environmental factors). A facility reported incident, dated 02/28/25,…
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 · E2025-02-14 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to determine if residents wished to formulate an advanced directive for 3 (#27, 46 and #49) of 13 sampled residents whose advance directive acknowledgements were reviewed. The DON identified 50 residents resided in the facility. Findings: An undated Advanced Directives policy, read in part, Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive. 1. Resident #27 was admitted on [DATE]. Their advance directive was not signed, nor did it indicate whether or not they had or wanted an advance directive. 2. Resident #46 was admitted on [DATE]. Their advance directive was signed, but did not indicate whether or not they had or wanted an advance directive. 3. Resident #49 was admitted on [DATE]. Their advance directive was signed, but did not indicate whether or not they had or wanted an advance directive. On 02/12/25 at 2:47 p.m., the business office manager stated at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-14 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide safe flooring in the common area where all halls connect to other common areas. The DON identified 50 residents resided in the facility and 35 residents whom were mobile with or without an assistive device in the facility. Findings: On 02/12/25 at 1:17 p.m., the facility was observed shaped like a wagon wheel, the halls were the spokes, and the nurses station was in the middle common area. Two of the floor slats were observed to be completely pulled away from the floor in the common area surrounding the nurses station. Maintenance was observed gluing down the two slats and holding them down with boxes waiting on the glue to dry. Multiple other floor slats were observed to have also previously been glued back down. Corners of floor slats were sticking up causing a potential tripping or injury hazard for all mobile residents, staff, or visitors. Maintenance was observed gluing down out of place slats on three different occasions throughout the survey. An undated facility Safe Environment policy, read 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.
- Potential for harm · Ecited before2025-02-14 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 medication carts were secured when not in use for two of two medication carts observed. The DON identified 50 residents resided in the facility. Findings: 02/10/25 at 4:44 p.m., the medication cart for hall 100 and 200 was observed by the nursing station (in the center of the building) to be unlocked and unattended with keys still in the lock. On 02/13/25 at 7:55 a.m., the medication cart on hall 600 was observed to be unlocked with no staff around. On 02/13/25 at 9:37 a.m., the medication cart on hall 600 was observed to be unlocked with no staff around. A Medication Storage policy, dated 01/08/24, read in part, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 02/10/25 at 4:46 p.m., LPN #2 stated leaving the medication cart unlocked and unattended was against policy. They stated, I'm sorry, it is my fault. On 02/13/25 at 8:01 a.m., LPN #1 stated, I am not supposed to leave the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure infection control was maintained and EBP were followed during medication administration to a resident with a PEG tube for one of one observation. The facility matrix identified 12 residents required enhanced barrier precautions. Findings: On 02/13/25 at 8:33 a.m., LPN #1 was observed providing crushed medications through a PEG tube to a resident that required EBP. LPN #1 washed their hands and wore gloves, but did not wear a gown while providing care to the indwelling device. An Enhanced Barrier Precautions policy, copyright date 2025, read in part, Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug resistant organisms .This facility utilizes Enhanced Barrier Precautions .as a strategy to decrease transmission of CDC [Centers for Disease Control and Prevention]-targeted and epidemiologically important MDROs when Contact Precautions do not apply .Enhanced Barrier Precautions: An infection control intervention designed to reduce…
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 before2024-08-23 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 residents were free from abuse for one (#147) of thirteen sampled residents reviewed for abuse. The DON identified 47 residents resided in the facility. Findings: Resident #147 was admitted [DATE] and had diagnoses which included hemiplegia, schizoaffective disorder, and epilepsy. Resident #147's care plan had not been initiated until 8/20/24. Their admission assessment was not due to be completed yet and had not been completed. An Initial and Final State Reportable Incident form, dated 08/15/24, documented an allegation of abuse/mistreatment. It documented that Resident #148 was in the human resources office voicing concerns over their camera being taken down off the wall. Resident #148 began to curse at the administrator. The administrator responded to resident say that to my face after slamming their hands on the desk. Resident #147 was removed from the situation and the administrator was suspended pending investigation. The ADON took…
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 · E2024-04-19 · 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 record review and interview, the facility failed to provide showers for two (#4 and #15) of two sampled residents reviewed for ADL assistance. The DON identified 46 residents who required assistance with ADLs resided in the facility. Findings: The Resident Showers policy, revised 10/01/23, read in part, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene . 1. Resident #15 had diagnoses which included multiple sclerosis and morbid obesity. On 04/15/24 at 3:00 p.m., Resident #15 stated their last bath was on 04/08/24. They stated they sometimes miss their baths. A Care Plan, read in part, .I have an ADL self care performance deficit. I am at risk for fluctuation of ADL care and staff assist . Shower Sheets, dated February 24, 2024 - March 18, 2024 were reviewed, There was no documentation Resident #15 received a shower for a total of 22 days. On 04/19/24 at 11:49 a.m. , the DON stated there was no other documentation or shower sheets to provide. There was no supporting documentation the resident received a shower from February 24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure a Resident's wall was in good repair for one (#45) of 16 sampled residents reviewed for home like environment. The Administrator identified 46 residents resided in the facility. Findings: The Safe and Homelike Environment policy, revised 10/23, read in part, .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment . Resident #45 had diagnoses which included cerebral infarction, abnormalities of gait, and mobility. On 04/15/24 at 3:17 p.m., Resident #45's wall had three deep scrapes by their head of the bed. Resident #45 was nonverbal. On 04/17/24 at 11:21 a.m., CNA #1 stated all maintenance needs were documented in the maintenance book. They stated they were aware of the deep scrapes in Resident #45's room since 02/24. On 04/17/24 at 11:22 a.m., CNA #1 stated they reported the deep scrapes on the wall to another staff. They stated they were not sure if the repair need was reported to maintenance. CNA #1 stated Resident #45's room is…
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
$131,280 in federal fines across 6 penalties. 2 Medicare payment denials on record.
- $23,431 — penalty dated 2026-02-18
- $26,685 — penalty dated 2026-02-18
- $17,799 — penalty dated 2025-08-18
- $40,912 — penalty dated 2025-06-02
- $10,712 — penalty dated 2024-08-23
- $11,741 — penalty dated 2024-05-22
- Medicare payment denial — starting 2025-03-14 for 7 days
- Medicare payment denial — starting 2024-10-02 for 6 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SELECTIS HEALTH INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/26/2021 |
| DESMOND, ADAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/18/2024 |
| ECKHART, KRYSTAL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/26/2021 |
| SELECTIS MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/26/2021 |
CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 84% 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 $120K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375582. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-18, 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.