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St. Ann's Skilled Nursing And Therapy

9400 St Ann's Drive, Oklahoma City, OK 73162 · For profit - Partnership · 120 certified beds · (405) 728-7888 Medicare & Medicaid certified

Call the home — (405) 728-7888 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Nov 2019
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Urgent care / clinic
8549 N Rockwell Ave · (405) 720-8316 · Call to confirm hours
Pharmacy
9000 NW Passage · (405) 773-3616 · Call to confirm hours
Grocery
7800 N.W. Expressway · (405) 323-0058 · Call to confirm hours
Park
8235 NW 104th St · (405) 678-0976 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 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 rating4★
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 increased8.9%13.6%15.4%better
Long-stay residents who lose too much weight1.8%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.7%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%2.8%2.0%better
Long-stay residents with depressive symptoms0.0%3.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.3%4.7%3.3%worse
Long-stay residents whose ability to walk worsened4.4%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.7%25.7%18.9%better
Long-stay residents given the seasonal flu vaccine97.8%94.6%95.3%typical
Long-stay residents with pressure ulcers6.7%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control19.3%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table7.8%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine84.8%74.1%79.4%typical
Short-stay residents rehospitalized after admission36.2%27.3%22.6%worse
Short-stay residents with an outpatient ER visit16.9%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.332.311.67worse
Long-stay outpatient ER visits per 1,000 resident days3.112.961.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

49.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 129 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.8%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
61.5%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 61.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 96 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 SNF49.8%CMS range 42.0–56.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.7–15.510.7%Oct 2022–Sep 2024no 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 discharge61.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge76.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.9%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 worsened0.6%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 hospitalization7.8%CMS range 5.2–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.46
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.26
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.37
RN hoursweekends
48.3%
Total nursing turnover
53.8%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 113.3 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 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 3.28 hrs/resident/day on weekends vs 3.72 on weekdays — 12% thinner on weekends. RN hours go from 0.50 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as 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

4
deficiencies at the latest standard inspection (2024-05-17)
3
at the previous standard inspection (2023-04-03)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Potential for harm · Dcited before2025-12-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure coordination of care with hospice services for 1 (#1) of 3 residents sampled for services per physician orders.The corporate nurse consultant identified 10 residents who received hospice services.Findings:A Hospice-Nursing Facility Contract, dated 07/08/25, read in part, Hospice and facility shall communicate with one another regularly and as needed for each particular hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of hospice patients are met 24 hours per day.An undated diagnosis report showed Res #1 had diagnoses which included Alzheimer's disease and dementia.A quarterly assessment, dated 10/25/25, showed Res #1 was severely cognitively impaired with a BIMS score of 00. The assessment showed Res #1 had no swallowing disorders and received hospice services.A nurse note, dated 11/04/25, showed Res #1 was declining in health with difficulty chewing 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 · Past Non-Compliance
  • Potential for harm · D2025-06-12 · 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 observation, record review, and interview, the facility failed to update a care plan for 1 (#14) of 22 sampled residents observed for accurate care plans. The DON identified 105 residents resided in the facility. Findings: On 06/12/25 at 1:37 p.m., Resident #14 was observed sitting up in bed at approximately a 75 degree angle and slowly feeding themselves. Most of their food was still on their plate. They stated, It would be nice if I had help. On 06/12/25 at 2:00 p.m., CNA #10 went in and asked if Resident #14 was done and then left the tray with them, but did not assist. A care plan, initiated on 10/06/21, showed Resident #14 required supervision or limited staff participation to eat. The care plan had not been revised. On 06/12/25 at 2:12 at p.m., CNA #10 stated, I don't know why [Resident #14] is in [their] room, I take care of the opposite side of the hall. I already went in there twice and [Resident #14] said [they were] fine. [Resident #14] is not a feeder as far as I know. We have a feeding table in the dining room for those that require assistance. [Resident #14]…

    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 before2025-06-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide eating assistance for 1 (#14) of 1 sampled resident observed for eating assistance. The DON identified 105 residents resided in the facility and eight residents required feeding assistance. Findings: On 06/12/25 at 1:37 p.m., Resident #14 was observed sitting up in bed at approximately a 75 degree angle and slowly feeding themselves. Most of their food was still on their plate. They stated, It would be nice if I had help. On 06/12/25 at 2:00 p.m., CNA #10 went in and asked if Resident #14 was done and then left the tray with them, but did not assist. A Nursing Skills Guideline, revised 03/2025, read in part, Our facility is committed to providing care that respects the dignity, preferences, and unique needs of each resident. Assistance with activities of daily living will be provided in a manner that prioritizes the resident's comfort, safety, and personal preferences .To ensure care aligns with the principles of person-centered care, enhancing the quality of life and satisfaction of our residents. 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 · Dcited before2025-06-12 · 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 the 5 rights of medication administration to prevent medication errors for 1 (#257) of 22 residents reviewed for medication administration. The DON identified 105 residents resided in the facility. Findings: A policy titled Preparation for Medication Administration, revised 12/01/12, read in part, Medications are administered at the time they are prepared .Residents are identified before medication is administered. The medication nurse or certified medication aide will turn to that resident's medication sheet, compare photo with resident and positively identify the resident. An incident note, dated 06/02/25 at 10:45 p.m., read in part, Medication aide stated to nurse that [they] had made a mistake while attempting to administer medication. [They] state[d] that [they] had two patients who take their medication with applesauce. [They] prepared one cup of medication, applied applesauce and placed it in the cart to give a potassium tablet time to dissolve due to patient being unable to take it whole. [They] then…

    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 · D2024-05-17 · tag F0641 — isolated
    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 accurately complete a resident assessment for one (#50) of 22 sampled residents reviewed for accurate assessments. The Administrator identified 106 residents resided in the facility. The Corp Nurse Consultant identified 28 residents who received anticoagulant medications. Findings: Resident #50 had diagnoses which included, heart disease, chronic obstructive pulmonary disease, and high cholesterol. A physician's order, dated 04/26/24, documented the resident was to be administered Aspirin 81 milligrams one tablet one time a day in the evening. A physician's order, dated 04/27/24, documented the resident was to be administered Plavix 75 milligrams one time a day. An admission Assessment, dated 05/02/24 documented Resident #50 received anticoagulant medications. On 05/13/24 at 12:26 p.m., Resident #50 was asked what all the bruising was on their arms. They stated My skin was thin and I take Plavix and Aspirin. On 05/16/24 at 11:40 a.m., MDS Coordinator #1 was shown the admission assessment and Resident #50's physician…

    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 · D2024-05-17 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation and interview, the facility failed to ensure a resident experiencing pain received treatment for pain for one sampled resident (#51) of 35 residents who receive pain medications and treatment. The DON stated 106 residents resided in the facility. Findings: A Pain policy revised, 09/10/07, read in part .1. The leadership of the long-term care facility must ensure that a commitment to resident comfort permeates all aspects of the facility's operation .2. Appoint a pain management coordinator with the responsibility for ensuring that all residents are properly assessed for pain and that all residents who have pain receive effective treatment. 4. Proper communication between teams members must be in place to ensure that information about the resident's pain is routinely conveyed and acted upon. Documentation should meet the same standards regardless of the nursing shift involved and communication between shift changes is vital . Resident (#51) had a diagnosis which included Syncope and Collapse. A Pain Care Assessment, last reviewed 05/11/24,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · 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 observation, record review, and interview, the facility failed to ensure a medication was available to administer for one (#209) of three sampled residents reviewed during medication observation. The administrator identified 106 residents resided in the facility. The Corp nurse consultant identified 106 residents received medications. Findings: A Medication Ordering and Receiving From Pharmacy policy, dated January 2022, read in part, .Medications and related products are received from the dispensing pharmacy on a timely basis . Resident #209's MAR documented 9 on 05/14/24 at 8:00 p.m., and 05/15/24 at 8:00 a.m. An Orders Administration Note, dated 05/15/24 at 8:14 a.m., read in part .Buprenorphine HCL Sublingual Tablet 2 MG .Ordered yesterday still haven't received order . An Orders Administration Note, dated 05/14/24 at 8:18 p.m., read in part .Buprenorphine HCL Sublingual Tablet 2 MG .waiting on pharmacy to deliver medication . On 05/15/24 at 9:18 a.m., the DON was asked why Resident #209's medication was not available to administer. They stated it was not in the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · 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 staff implemented infection control measures (sanitized their hands) while passing medications. The Administrator identified 106 residents resided in the facility. The Corp Nurse Consultant identified 106 residents received medications. Findings: A Hand Hygiene policy, dated 10/07/03, read in part, .Hand hygiene the simple and effective method of preventing the spread of pathogens which cause infections .Failure to properly clean hands can result in the spread of these pathogens to residents .The singe most important step in the prevention of infection is hand hygiene . On 05/15/24 at 7:55 a.m., CMA #1 was observed to pop a tablet of Eliquis that fell in the open med cart drawer. CMA #1 then popped another pill that fell on the floor. CMA #1 was observed to pick the pill up off the floor and throw it in the trash on the end of the cart. They were not observed to sanitize their hands then continued to pop the rest of Resident # 210's medications (four meds). Then administered the medications to the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-03 · 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

    Based on record review and interview, the facility failed to ensure bathing was offered to resident (#3 and #31) of five sampled residents reviewed for bathing. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 101 residents resided in the facility. Findings: 1. Resident #3 had diagnoses which included mood disorder with anxiety. Resident #3's ADL's report, admission date 01/05/22, documented bathing was scheduled for Wednesdays and Saturdays on the 3-11 shift. The annual resident assessment, dated 01/06/23, documented the resident's cognition was intact. It documented the showers were very important, the resident required physical help of one person for bathing, and the resident had no documented rejection of care. On 03/29/23 at 7:19 a.m., Resident #3 stated they had not been receiving showers. Resident's #3's Documentation Survey Report form, dated January 2023, documented the resident was offered two out of eight baths and had received one out of eight opportunities for baths. Resident's #3's Documentation Survey Report form, dated February 2023,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure a clean homelike environment was provided for two (#4 and #48) of 32 sampled residents reviewed for environment. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 101 residents resided in the facility. Findings: A Housekeeping policy, revised 06/29/12, read in part, .Cleaning procedures for the facility are carried out on a daily and weekly basis .There may also be resident rooms that require more than just daily cleaning . On 03/29/23 at 8:47 a.m., a wipe was observed under the head of Resident #48's bed. Dried, light, brown liquid was observed on the floor approximately two feet from the bed. A torn alcohol pad was observed on the floor next to the dried brown liquid. A white straw, black stir stick, and white tissue were observed on the floor, under the bed near the wall. On 03/29/23 at 9:13 a.m., CNA #1 was asked how staff ensured residents' rooms were cleaned. They stated they notify housekeepers when they needed to. CNA #1 stated they would call for a housekeeper…

    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
Show the remaining 12 citations
  • Potential for harm · D2023-04-03 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide a pest free environment for one (#3) of five sampled residents reviewed for pest control. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 101 residents resided in the facility. Findings: A Pest Control Policy policy, dated 10/24/2008, read in parts, .It is the policy of this facility to maintain an effective pest control program so that the facility is free of pest and rodents. The purpose of a pest control program is .to correct or eliminate infestation already in existence .The practice of preventative pest control is considered to be most economical and effective means of protecting our residents, employees and visitors .Maintenance personnel should ensure that the facility is free of herbage areas within the facility. All cracks and crevices should be sealed .The administrator is ultimately responsible for monitoring and delegating of the department functions . The facility's Completed Work Order, reviewed 12/01/22 though 03/30/23 did not contain documentation of…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-11-13 · 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

    Based on observation, record review and resident, family and staff interviews, it was determined the facility failed to ensure there was adequate staff to provide activities of daily living (ADLs) to dependent residents for one (#36) of two sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility, 58 residents required assistance of one or more with bathing and 81 residents required assistance of one or more with transfers. Findings: Resident #36 had diagnoses which included Parkinson's disease, unspecified visual loss and a history of falling. A quarterly resident assessment, dated 08/25/19, documented the resident's cognition was moderately impaired. She required extensive assistance with transfers and physical help in part of bathing activity. The resident's bathing record documented the resident was to be bathed on Tuesdays, Thursdays and Saturdays. It documented during the weeks of 09/15/19 through 09/21/19, 10/06/19 through 10/12/19 and 10/20/19 through 10/26/19 the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-11-13 · 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 — the official record, unedited, may be distressing

    Based on record review and staff interview, it was determined the facility failed to ensure physician's orders were followed to obtain daily weights for one (#243) of three sampled residents reviewed for weights. The facility identified one resident with orders for daily weights. Findings: Resident #243 had diagnoses which included congestive heart failure (CHF). He discharged from the facility on 07/26/19. A physician's order, dated 07/14/19, documented, .daily weight Dx [diagnosis] :CHF one time a day related to HYPERTENSIVE HEART DISEASE WITH HEART FAILURE . A vital signs report documented the resident had been weighed on 07/19, 07/21 and 07/22/19. On 11/06/19 at 12:36 p.m., the corporate nurse was shown the order for daily weights. She reviewed the resident's clinical record. She was asked if weights had been obtained as ordered. She stated staff obtained weights on 07/19, 07/21 and 07/22/19. She acknowledged the findings.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-11-13 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and resident, family and staff interviews, it was determined the facility failed to ensure there was adequate staff to provide activities of daily living (ADLs) to dependent residents for one (#36) of two sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility, 58 residents required assistance of one or more with bathing and 81 residents required assistance of one or more with transfers. Findings: Resident #36 had diagnoses which included Parkinson's disease, unspecified visual loss and a history of falling. A quarterly resident assessment, dated 08/25/19, documented the resident's cognition was moderately impaired. She required extensive assistance with transfers and physical help in part of bathing activity. The resident's bathing record documented the resident was to be bathed on Tuesdays, Thursdays and Saturdays. It documented during the weeks of 09/15/19 through 09/21/19, 10/06/19 through 10/12/19 and 10/20/19 through 10/26/19 the 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-11-13 · 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 record review and staff interview, it was determined the facility failed to ensure medications were administer as ordered for one (#33) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: Resident #33 had diagnoses which included abnormal sputum and anemia. A physician's order, dated 06/12/19, documented, .Vitamin C Tablet .Give 500 mg [milligrams] by mouth two times a day for Supplement . A physician's order, dated 09/02/19, documented, .Mucinex Allergy Tablet .Give 600 mg by mouth two times a day .for 7 Days . The scheduling details for the order documented the Mucinex was to be started on 09/02/19 on the evening shift. The September 2019 medication administration record (MAR) documented Mucinex was coded as a 9 which indicated other/see nurse notes for the following: ~ on 09/02/19 on the evening shift and ~ on 09/03/19 on the morning shift. It was documented the last dose had been administered on 09/09/19 on the morning shift. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-11-13 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, it was determined the facility failed to ensure laboratory tests were obtained as ordered for two (#72 and #243) of five sampled residents reviewed for laboratory (lab) services. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: 1. Resident #243 had diagnoses which included congestive heart failure. A physician's progress note, dated 07/24/19, documented, .Will go ahead and get another set of labs .Plan: recheck labs . A physician's order, dated 07/24/19, documented, .CMP [comprehensive metabolic panel] .CBC [complete blood count] . On 11/06/19 at 12:36 p.m., the corporate nurse was shown the order for lab and asked if it had been collected. She reviewed the lab program and acknowledged the lab had not been drawn. 2. Resident #72 had diagnoses which included dementia. A physician's order, dated 10/31/19, documented, CBC, CMP .due to increased confusion . On 11/06/19 at 8:15 a.m., the receptionist was asked to provide lab results for the above order. At 9:46…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-11-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, it was determined the facility failed to ensure: ~ food products were properly stored to prevent cross-contamination, ~ food products were discarded at designated times and ~ the floor was maintained in good repair. The facility identified 100 residents received services from the kitchen. Four residents received nutrition and hydration solely through a feeding tube. Findings: On 11/03/19 at 7:36 a.m., a tour of the kitchen was conducted. The following observations were made: ~ multiple raw hamburger patties were stored on a plate in a metal container next to plates of cut tomatoes, lettuce and slices of cheese on a shelf in the walk-in cooler. The metal container was stored above a ten pound box of fully cooked sausage links and a metal container of cooked sloppy joes, ~ a 30 pound box of raw bacon was stored on a shelf next to a 20 pound box of romaine lettuce in the walk-in cooler, ~ a 12 pound box of raw pork sausage patties was stored on a shelf next to a metal container of cooked sloppy joes in the walk-in cooler, ~ a 12 count carton of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-13 · 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 staff interview, it was determined the facility failed to ensure the physician and the resident's representative was notified of a fall for one (#292) of three sampled residents reviewed for falls. The Resident Census and Condition of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: Resident #292 had diagnoses which included hemiplegia and hemiparesis. On 11/13/19 at 8:02 a.m., the resident and his family member were asked if he had sustained any falls. They stated he fell in the dining room around 6:30 a.m. Sunday morning. The resident was asked if he had hit his head or passed out. He stated he did not hit his head or pass out. He stated he was ok and the wheel chair got away from me. Nurses' notes were reviewed for the resident. There was no documentation to show the resident sustained a fall the morning of 11/10/19. There was no documentation to show the physician and resident's representative was notified of the fall. At 9:08 a.m., licensed practical nurse (LPN) #2 was asked if she had worked last Sunday,…

    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 · D2019-11-13 · 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 — the official record, unedited, may be distressing

    Based on record review and staff interviews, it was determined the facility failed to implement their abuse policy by not conducting employee reference checks for one (licensed practical nurse (LPN) #1) of five employee files reviewed. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: A resident abuse, neglect and misappropriation of property policy, revised 12/28/17, documented, .The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .Screening/Prevention .All potential employees will be screened for previous history of abuse by .and other reference checks . LPN #1 was hired on 09/27/19. There was no documentation employee reference checks had been conducted. On 11/05/19 at 9:11 a.m., the corporate nurse was asked to provide documentation reference checks had been conducted for LPN #1. At 11:43 a.m., the administrator stated she had to assume reference checks for LPN #1 had not been completed.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-13 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, it was determined the facility failed to complete a quarterly resident assessment for one (#292) of 17 sampled residents reviewed for resident assessments. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in facility. Findings: Resident #292 had diagnoses which included candidal sepsis, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus with diabetic polyneuropathy and retention of urine. An annual resident assessment was completed on 06/22/19. A quarterly resident assessment was due to be completed in September 2019. There was no documentation a quarterly assessment had been completed. On 11/12/19 at 12:23 p.m., the minimum data set coordinator was asked to review the resident's assessments. She was asked if a quarterly assessment for the resident should have been completed in September 2019. She stated, Yes, he should have had a quarterly done in September.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-13 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, it was determined the facility failed to ensure the physician was notified of abnormal laboratory (lab) test results for one (#21) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: Resident #21 had diagnoses which included dysuria. A physician's progress note, dated 10/24/19, documented, .Dysuria .I am going to add UA [urine analysis] with culture . A physician's telephone order, dated 10/24/19, documented, .UA [with] C & S [culture and sensitivity] . A lab service report, dated 10/26/19, documented abnormal results, .URINE CULTURE .ORGANISM .ESCHERICHIA COLI .10,000-50,000 . There was no documentation the physician had been notified of the lab results. On 11/12/19 at 11:42 a.m., the corporate nurse was shown the urine culture results and was asked if the physician had been notified. She stated, If the doctor's initials are not on it or the nurses didn't write fax like on the other ones, then no.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-13 · 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 staff interview, it was determined the facility failed to ensure a resident's clinical record was complete and accurate regarding a fall for one (#292) of three sampled residents reviewed for falls. The Resident Census and Condition of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: Resident #292 had diagnoses which included hemiplegia and hemiparesis. On 11/13/19 at 8:02 a.m., the resident and his family member were asked if he had sustained any falls. They stated he fell in the dining room around 6:30 a.m. Sunday morning. The resident was asked if he had hit his head or passed out. He stated he did not hit his head or pass out. He stated he was ok and the wheel chair got away from me. Nurses' notes were reviewed for the resident. There was no documentation to show the resident sustained a fall the morning of 11/10/19. At 9:08 a.m., licensed practical nurse (LPN) #2 was asked if she had worked last Sunday, 11/10/19. She stated yes, she had worked the 11:00 p.m. to 7:00 a.m. shift on Saturday night. The LPN 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.

    Resident Assessment and Care Planning 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to BRIDGES HEALTH — 33 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 4 of 53.6+0.4 vs chain
Health inspection 4 of 53.5+0.5 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 3 of 53.0≈ chain avg
The other 32 homes this chain runs (chain average 3.6★, per CMS)
1 of 5Brookwood Skilled Nursing and TherapyOklahoma City, OK 1 of 5The Timbers Skilled Nursing and TherapyEdmond, OK 2 of 5Ambassador Manor Nursing CenterTulsa, OK 2 of 5Fairmont Skilled Nursing and TherapyOklahoma City, OK 2 of 5Grace Skilled Nursing and Therapy JenksJenks, OK 2 of 5Stillwater Creek Skilled Nursing And TherapyStillwater, OK 2 of 5The Grand At Bethany Skilled Nursing And TherapyBethany, OK 3 of 5Capitol Hill Skilled Nursing And TherapyOklahoma City, OK 3 of 5Claremore Skilled Nursing and TherapyClaremore, OK 3 of 5Glenwood Skilled Nursing And TherapyGlenpool, OK 3 of 5The Springs Skilled Nursing And TherapyMuskogee, OK 3 of 5The Wilshire Skilled Nursing And TherapyOklahoma City, OK 3 of 5Wildewood Skilled Nursing And TherapyOklahoma City, OK 4 of 5Bradford Village Healthcare CenterEdmond, OK 4 of 5Cottonwood Creek Skilled Nursing & TherapyChickasha, OK 4 of 5English Village Skilled Nursing And TherapyAltus, OK 4 of 5Heritage Skilled Nursing And TherapyTecumseh, OK 4 of 5Kingwood Skilled Nursing and TherapyOklahoma City, OK 4 of 5Magnolia Creek Skilled Nursing And TherapyAltus, OK 4 of 5Mid-Del Skilled Nursing And TherapyDel City, OK 4 of 5Sequoyah Pointe Skilled Nursing And TherapyTahlequah, OK 4 of 5The CommonsEnid, OK 4 of 5University Park Skilled Nursing And Therapy MemoryTahlequah, OK 4 of 5Woodward Skilled Nursing And TherapyWoodward, OK 5 of 5Grace Skilled And Nursing Therapy NormanNorman, OK 5 of 5Holiday Heights HealthcareNorman, OK 5 of 5Mangum Skilled Nursing And TherapyMangum, OK 5 of 5River Oaks Skilled Nursing And TherapyEl Reno, OK 5 of 5River Valley Skilled Nursing And TherapyClinton, OK 5 of 5Senior Village HealthcareBlanchard, OK 5 of 5The Regency Skilled Nursing And TherapyShawnee, OK 5 of 5Western Skilled Nursing And TherapyBuffalo, OK

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
BRIDGES EMPLOYEE STOCK OWNERSHIP TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 12/31/2020
DEROIN, KRISTYIndividualW-2 MANAGING EMPLOYEEsince 12/31/2020
COBLE, WILLIAMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/31/2020
BRIDGES ESOP, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/31/2020

CMS files one row per role, so the 5 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.

$10.1M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$695K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 8%Other / private 25%

This home reported $695K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$280per resident / day
operating cost
$8,518per month
≈ monthly operating cost
$279per 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 375561. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-17, 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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