The Lakes
5701 West Britton Road, Oklahoma City, OK 73132 · For profit - Individual · 120 certified beds · (405) 773-8900 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $19,073 in federal fines (most recent 2024-11-21)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.7% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.4% | 3.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.1% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.7% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 7.0% | 3.4% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.7% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.2% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.3% | 25.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.8% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.1% | 17.5% | 17.1% | worse |
| Short-stay residents given the seasonal flu vaccine | 47.6% | 74.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.8% | 27.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 23.8% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.09 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.30 | 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 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 10.0%CMS range 6.6–16.1 | 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 | 100.0% | 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 | 3.3% | 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 | 16.7% | 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 | 8.2%CMS range 4.6–14.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.38 | 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 120 beds and averages 77.6 residents a day — about 65% occupied, or roughly 42 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 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 3.81 hrs/resident/day on weekends vs 4.06 on weekdays — 6% thinner on weekends. RN hours go from 0.47 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% 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
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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-10-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 10/09/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide adequate supervision to prevent elopement for Resident #1 with severe cognitive impairment, daily wandering behaviors, and a history of elopement. An initial State Reportable Incident, dated 10/06/24, documented the facility charge nurse was called and notified by the local church Resident #1 was at their facility. It documented the resident was assessed and noted to have bruising to left and right lower extremities, and bilateral knees. It documented the resident reported they fell but did not hit their head. It documented the resident was sent to the ER and would be placed on 1:1 with staff to ensure safety. An Incident Note, dated 10/06/24 at 1:29 p.m., documented Resident #1 returned to the facility from the hospital with no new orders. Staffing assignment sheets were reviewed from 10/06/24 through 10/09/24. There was no documentation 1:1 was completed by staff on 10/06/24 for the day 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 · Gcited before2024-12-18 · 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
Based on observation, record review, and interview, the facility failed to prevent a resident from a fall resulting in a close head injury during the provision of care for one (#3) of three sampled residents reviewed for accidents. The administrator identified 67 residents resided in the facility and 34 residents required assistance with activities of daily living. Findings: The Safety and Supervision of Residents policy, revised 07/2017, read in part, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident #3 had diagnoses which included vascular dementia and Alzheimer's disease. Resident #3's care plan for ADLs and falls, revised 10/29/24, documented the resident: a. was dependent on staff for bed mobility, b. was totally dependent on staff for repositioning and turning in bed, c. required total assistance with transfers, and d. was at risk for falls. Resident #3's quarterly resident assessment, dated 10/30/24, documented the resident had severe cognitive impairment and was dependent on staff for toileting hygiene. The assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · 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
Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#2) of three sampled residents reviewed for abuse. The administrator identified 67 residents resided in the facility. Findings: The Abuse and Neglect Clinical Protocol policy, revised 07/2017, read in part, Sexual abuse is defined .as non-consensual sexual contact of any type with a resident. Resident #2 had diagnoses which included dementia and senile degeneration of brain. Resident #2's quarterly resident assessment, dated 10/23/24, documented the resident had severe cognitive impairment. An Initial State Reportable Incident form, dated 12/02/24, documented an allegation of abuse/mistreatment. It documented Resident #4 was witnessed putting their hand on Resident #2's crotch while sitting at the TV area. It documented Resident #4 was immediately removed from the area and placed on one on one with staff. It documented no injury noted to Resident #2 who was unable to answer any questions regarding the situation. On 12/17/24 at 9:57 a.m., Housekeeper #1 stated they observed…
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 · E2024-11-21 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident with a new diagnosis of a serious mental health condition had a pre-admission screening and resident review updated for one (#1) of one sampled resident reviewed for PASARR level two. The DON identified 28 residents with serious mental health diagnoses. Findings: The facility policy titled, admission Criteria, read in part, Nursing and medical needs of individuals with mental disorders, intellectual disabilities will be determined by coordination with the Medicaid Pre-admission and Resident Review program (PASARR) to the extent possible. Resident # 1 had diagnoses which included psychosis, anxiety, and recurrent depression. Resident #1's Nursing Level of Care Assessment, dated 01/23/18, did not document they had any serious mental health conditions. The primary diagnosis was listed as multiple sclerosis. A review of the order summary medical diagnoses list documented Resident #1 had the following new diagnoses after the initial PASARR was completed in 2018: a. anxiety with an onset date of 09/11/18; b.…
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 · E2024-11-21 · 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
Based on record review and interview, the facility failed to develop a comprehensive care plan for: a. IV and antibiotic usage for one (#20); b. visual function for one (#6); and c. antipsychotic medication use for one (#35) of 18 sampled residents whose care plans were reviewed. The DON identified 71 residents who resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised 12/16, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Resident #20 had diagnoses which included metabolic encephalopathy, chronic kidney disease, and urinary tract infection. A progress note, dated 11/03/24 at 2:31 p.m., documented they received a urine culture report and the resident would need a midline or PICC placement for IV antibiotic. It documented the resident was sent to the emergency room for a long term access device placement and to receive their first dose of antibiotic for monitoring…
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 before2024-11-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure wound treatments were provided for one (#18) of two sampled residents reviewed for pressure ulcers. The DON identified three residents had been admitted to the facility with wounds since 10/01/24. Findings: An undated facility policy, Guidelines for Notifying Physician of Clinical Problems, read in part, These guidelines are to help ensure that .medical problems are communicated to the medical staff in a timely efficient manner .The charger nurse or supervisor should contact the attending physician at anytime if they feel a clinical situation requires immediate discussion and management .the nurse should have the the following information available .active medical problems. The admission Assessment and Follow Up: Role of the Nurse, last revised September 2012, read in part, conduct a physical assessment including .skin .contact the attending physician to communicate and review the findings of the initial assessment and any other…
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 before2024-11-21 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to: a. ensure an insulin label indicated the order had changed for one (#41); and b. ensure medications were administered following standards of practice for one (#41) of ten sampled residents observed during medication pass. The DON identified five residents with orders for a lidocaine patch. The Resident Matrix, dated 11/18/24, documented 16 residents received insulin. Findings: An Administering Topical Medications policy, revised 10/10, read in part, The purpose of this procedure is to provide guidelines for the safe administration of topical medications .Apply glove to your dominant hand .assess area for .debris .Clean the skin. Remove old medication residue .Don clean gloves if necessary .Trans-dermal patches .Clean and dry a selected area that is approved for application of the patch. Rotate sites with each new application, if possible. An Insulin Administration policy, revised 09/2014, read in part, To provide guidelines for the safe administration of insulin to residents with diabetes .The type 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.
- Potential for harm · E2024-11-21 · 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 record review and interview, the facility failed to: a. maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system; b. adhere to enhanced barrier precautions for one (#18) of 18 sampled residents reviewed for infection control; c. remove gloves and/or wash or sanitize hands in order to prevent cross contamination for six (#2, 22, 23, 26, 41, and #49); and d. clean out the nebulizer canister after use for one (#26) of ten sampled residents observed during medication pass. The DON identified 71 residents resided in the facility and eight residents with orders for nebulizer treatments. The Resident Matrix, dated 11/18/24, documented 16 residents received insulin. Findings: A Pulse Oximetry policy, revised 10/2010, read in part, Steps to procedure .Perform hand antisepsis .Remove probe when monitoring is complete .Perform hand antisepsis. The Respiratory Therapy Prevention of Infection policy, revised 11/2011, 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 · E2024-11-21 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 facilty failed to provide documentation the facility administered the pneumococcal vaccine for two (#62 and #69) of five sampled residents reviewed for immunizations. The DON identified 71 residents who resided in the facility. Findings: A Pneumococcal Vaccine policy, dated 8/2016 read in part, Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility. 1. Resident #62 was admitted to the facility on [DATE]. The pneumococcal consent was signed on 12/04/23. The immunization record for the resident did not document the pneumococcal vaccine was administered. 2. Resident #69 was admitted to the facility on [DATE]. The pneumococcal consent was signed on 05/02/24. The immunization record for the resident did not document the pneumococcal vaccine was administered. On 11/21/24 8:38 a.m., the DON stated they were not able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to notify the attending physician of a wound without a treatment order for one (#18) of two sampled residents with wounds. The DON identified three residents had been admitted to the facility with wounds since 10/01/24. Findings: An undated facility policy, Guidelines for Notifying Physician of Clinical Problems, read in part, These guidelines are to help ensure that .medical problems are communicated to the medical staff in a timely efficient manner .The charger nurse or supervisor should contact the attending physician at anytime if they feel a clinical situation requires immediate discussion and management .the nurse should have the the following information available active medical problems. The admission Assessment and Follow Up: Role of the Nurse, last revised September 2012, read in part, conduct a physical assessment including skin .contact the attending physician to communicate and review the findings of the initial assessment 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.
- Potential for harm · Dcited before2024-11-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a MDS was coded accurately for one (#30) of 18 sampled residents reviewed for accuracy of MDS assessments. The DON identified 71 residents resided in the facility. Findings: Resident #30 had diagnoses which included spondylosis and peripheral vascular disease. An admission assessment, dated 10/31/24, documented the resident had an indwelling catheter. On 11/20/24 at 12:45 p.m., MDS coordinator #2 stated Resident #30 did not have a catheter. They stated for some reason the system auto populates. MDS Coordinator #1 stated they would do a correction and that was not the only one. They stated they needed to pay better attention and it was not coded accurately.
- Potential for harm · D2024-11-21 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to complete a discharge summary for one (#72) of one sampled resident reviewed for discharge. The Admission/Discharge To/From Report, dated 05/01/24 through 11/18/24, documented 10 residents discharged from the facility within the last six months. Findings: Res #72 discharged from the facility on 09/03/24 after a respite stay since 08/26/24. A communication note, dated 09/03/24 at 4:37 p.m., documented, Resident picked up by transport to be taken home. Wife, Hospice, ADON and PA aware. Personal belongings and medications given to transport. There was no documentation a discharge summary had been completed. On 11/19/24 at 11:16 a.m., LPN #3 stated they did not see the summary. They stated the policy was to document where the resident was going, how they discharged , any teaching, medications, a brief summary, who picked them up, and details of the stay.
Show the remaining 14 citations
- Potential for harm · D2024-11-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure: a. oxygen tubing was changed; and b. oxygen was administered as ordered for one (#6) of one sampled resident reviewed for oxygen. The DON identified six residents with orders for oxygen resided in the facility. Findings: An Oxygen Administration policy, revised 10/2010, read in part, The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify there is a physician's order for this procedure .After completing the oxygen setup .the following information should be recorded in the resident's medical record .The date and time that the procedure was performed .The rate of oxygen. The Respiratory Therapy Prevention of Infection policy, revised 11/2011, read in part, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy .Check water levels of refillable humidifier units daily when humidified O2 is used .Change the reservoir every forty-eight (48) hours when humidified O2 is used. Resident #6 had diagnoses which included chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure treatment carts were secured when not in use for one observation observed on hall 500 for medication storage. The DON identified 71 residents resided in the facility. Findings: A Storage of Medication policy, dated 4/2007, read in part, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy also read, Compartment (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 11/19/24 at 3:30 p.m., LPN #2 was observed preparing to do wound care. They were observed to walk away from the unlocked treatment cart and walk up the hall towards the nurses station. On 11/19/24 at 3:32 p.m., LPN #2 returned to the cart. They stated they left the cart unlocked and the policy for securing medications was to lock the cart when they walk away from…
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 · E2024-10-11 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to implement their abuse policy for three (#2, 5, and #6) of three sampled residents reviewed for abuse. The DON identified 70 residents resided in the facility. Findings: An Abuse Investigation and Reporting policy, revised 07/17, read in part, .All reports of resident abuse, neglect .shall be promptly reported to local, state and federal agencies .and thoroughly investigated by facility management .The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation .Role of the Investigator .The individual conducting the investigation will, as a minimum .Interview the person reporting the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, and visitors .Interview other residents .Review all events leading up to the alleged incident .Witness…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-11 · 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 report an allegation of abuse to APS and local law enforcement for two (#5 and #6) of three sampled residents reviewed for abuse. The DON identified 70 residents resided in the facility. Findings: An Abuse Investigation and Reporting policy, revised 07/17, read in part, .All reports of resident abuse, neglect .shall be promptly reported to local, state and federal agencies .All alleged violations involving abuse .will be reported by the facility Administrator .to the following persons or agencies .Adult Protective Services .Law enforcement officials . 1. Resident #5 had diagnoses which included dysphagia following cerebral infarction and osteoporosis. A Quarterly Resident Assessment, dated 06/10/24, documented Resident #5 had moderate cognitive impairment. A Quarterly Resident Assessment, dated 09/10/24, documented Resident #5's cognition was intact. 2. Resident #6 had diagnoses which included unspecified dementia without behavioral disturbances, Alzheimer's disease, and psychotic disorder with delusions. An admission…
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 before2024-08-12 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 wound and skin assessments were completed for one (#1) of three sampled residents reviewed for wounds and skin assessments. The director of nursing identified 26 residents with skin issues and/or wounds. Findings: Resident #1 was admitted to the facility on [DATE] with diagnosis to include pressure ulcer to right heel, diabetes mellitus with polyneuropathy, congestive heart failure, cerebral infarction, and hemiplegia and hemiparesis. Resident #1 wound and skin noted dated 06/07/24 at 10:34 p.m., documented the resident had wounds to the right heel and great toe. The note indicated the measurements of the heel wound was 8 cm X 3.5 cm with a depth of 0.1 cm. The heel was dry, hard to touch with a white center and the outer wound was black. There was no additional documentation of the wound to the great toe. Resident #1 admission summary, dated [DATE], read in part, .Pressure injury noted to R heel 8cmx3.5 cm, dry and hard to touch, center white,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-12 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
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 medical records were provided within two working days for one (#1) of one sampled residents reviewed for medical records request. The administrator identifed only one record request since 06/01/24, and 64 residents who resided in the facility Findings: An undated policy, Release of Information, read in part, .A resident may obtain photocopies/electronic versions of their records by providing the facility with at least a forty-eight (48) hour (excluding weekends and Holidays) advance notice of such request .it may require additional time produce up to 5 business days based on the volume . Resident #1 was admitted to the facility on [DATE] with diagnosis to include pressure ulcer to right heel, diabetes mellitus with polyneuropathy, congestive heart failure, cerebral infarction, and hemiplegia and hemiparesis. Resident #1 face sheet documented their spouse was the power of attorney and responsible party. An Authorized to Use or Disclose Health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure stored and opened food items were dated or labeled inside of the refrigerator. The Resident Census and Conditions of Residents report, dated 09/26/23, documented 59 residents resided in the facility. The DON identified 54 residents received their meals from the kitchen and three residents receive nothing by mouth. Findings: A Date Marking policy, dated 12/22, read in part, All food and supply items in the Dietary Department should be date [sic] and marked with received date, Items removed from the master case must be marked individually with received date .Once items are removed from the original packaging and placed in alternate storage containers, the alternate storage container must have received date and transfer date .Commercially prepared products that have been individually marked with a receipt date should be marked once opened with an open date .Once product is removed from original package, product should be .marked with open date .Cooked, prepared food should be sealed and marked with prep date .if product…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure a call light was in reach for one (#25) of 24 sampled residents reviewed for call lights. The Resident Census and Conditions of Residents report, dated 09/26/23, documented 59 residents resided in the facility. Findings: The facility's Answering the Call Light policy, revised 10/10, read in part, .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Resident #25 had diagnoses which included hemiplegia and hemiparesis. Resident #25's quarterly resident assessment, dated 07/26/23, documented the resident was cognitively intact and required two person physical assist for transfers. It documented the resident had a functional limitation in range of motion impairment on one side for the upper and lower extremity. Resident #25's care plan for fall, dated 07/28/23, documented Resident #25 was at risk for falls with interventions that included to ensure the Resident's call light was in reach. On 09/26/23 at 1:49 p.m., Resident #25 was in a wheelchair…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 grooming for one (#4) of two sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 09/26/23, documented 59 residents resided in the facility and required some assistance with ADLs. Findings: Resident #4 had diagnoses which included hemiplegia and dementia. Resident #4's care plan for ADLs, dated 09/04/23, documented Resident #4 required staff participation with personal hygiene. Resident #4's admission resident assessment, dated 09/08/23, documented the resident was cognitively intact and required one person physical assist for personal hygiene. It documented the resident had a functional limitation in range of motion impairment on one side for the upper and lower extremity. On 09/26/23 at 11:02 a.m., Resident #4 was observed with white hairs on their chin. Resident #4's left hand was contracted. On 09/26/23 at 1:25 p.m., Resident #4 touched their chin and stated they would like to be shaved. On 09/28/23 at 8:49 a.m., Resident #4 was observed with white…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-08 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 complete weekly skin assessments for a resident with wounds for one [#43] of one sampled resident reviewed for non pressure skin conditions. The Resident Census and Conditions of Residents report, dated 06/02/22, documented 56 residents resided in the facility. Findings: Resident #43 was re-admitted on [DATE] with diagnoses which included cerebral infarction and hemiplegia. A Skin/Wound Note, dated 05/13/22, documented the resident had wounds on their bilateral lower legs and toes. There was no documentation weekly skin assessments had been completed for the week of 05/15/22, 05/22/22, and 05/29/22. On 06/06/22 at 10:57 a.m., LPN #1 was asked if Resident #43 had any skin issues. They stated they were re-admitted with wounds to their toes and legs. They were asked where skin assessments were documented. They stated they were documented under assessments. LPN #1 was asked how often skin assessments were to be completed. They stated weekly. LPN #1 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure weekly skin assessments were conducted for one (#27) of one sampled resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 06/02/22, documented 56 residents resided in the facility and one resident had a pressure ulcer. Findings: Resident #27 had diagnoses which included unstageable pressure ulcer to the right heel. A Skin/Wound note, dated 01/28/22, documented, Weekly Skin Check done by nurse . Location of Wound: R. heel . Type of Wound: open blister .Measurement .3cm diameter .Wound Characteristics:(describe): draining serous drainage . A Skin/Wound note, dated 03/15/22, documented, Weekly Skin Check done by nurse .Location of Wound: Heel Right .Measurement .Heel R. 3cm diameter .Wound Characteristics:(describe): Non draining with echar [sic] R. heel. Blister R. shin dry and scabbed . A Skin/Wound note, dated 04/29/22, documented, Weekly Skin Check .Location of Wound: right heel .Type of Wound: open .Measurement .4x4 cm .Measurement-Depth (cm): 0.25 cm Wound…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-06-08 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident was provided services to prevent further decrease in range of motion for one (#43) of one sampled resident reviewed for limited range of motion. The Resident Census and Conditions of Residents report, dated 06/02/22, documented 18 residents who had contractures. The DON identified there were no residents receiving restorative services. Findings: Resident #43 was re-admitted with diagnoses which included cerebral infarction and hemiplegia. An admission Summary, dated 05/12/22, documented the resident had decreased movement of their left and right lower extremities, and had decreased grasp of their left hand. A Physician's Order, dated 05/12/22, documented may participate in restorative/functional maintenance programs as desired. On 06/02/22 at 9:36 a.m., Resident #43 was observed to have a left hand contracture with no support present. On 06/06/22 at 11:03 a.m., LPN #1 was asked if Resident #43 had any contractures. They stated the residents' left hand was a little rigid and they moved it, but it was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-08 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure medications were administered to the correct resident for one (#105) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 06/02/22, documented 56 residents resided in the facility. Findings: An Adverse Consequences and Medication Errors policy, revised April 2014, documented, .A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders .a drug is administered without a physician's order . Resident #105 had diagnoses which included anxiety. A resident assessment, dated 05/17/21, documented Resident #105's cognition was intact. An Incident Report form, dated 05/20/21, read in part, .[LPN #2] was working the 11-7 [11:00 p.m.-7:00 a.m.] shift .administered the wrong medication to Resident #105]. Within 5 minutes of the error, [LPN #2] went back to the resident and told [Resident] that [LPN #2] had administered the wrong medications to [Resident #105]. The resident leaned over 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 before2022-06-08 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an MDS was coded accurately for pressure ulcers for one (#27) of 11 sampled residents reviewed for accurate MDS assessments. The Resident Census and Conditions of Residents report, dated 06/02/22, documented 56 residents resided in the facility. Findings: An RAI Coding Instructions for MDS assessments, dated October 2019, documented, .Stage 2 Pressure Ulcer .May also present as an intact or open/ruptured blister .Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore stage) cannot be determined . Resident #27 had diagnoses which included unstageable pressure ulcer to the right heel. A Skin/Wound note, dated 01/28/2022, documented, .Weekly Skin Check done by nurse .Location of Wound: R. heel .Type of Wound: open blister .Measurement .3cm diameter . A Skin/Wound note, dated 03/15/2022, documented, Weekly…
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
$19,073 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $11,052 — penalty dated 2024-11-21
- $8,021 — penalty dated 2024-10-11
- Medicare payment denial — starting 2024-11-02 for 14 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.
Part of a chain
This home belongs to PHOENIX HEALTHCARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 4 of 5 | 3.2 | +0.8 vs chain |
| Quality measures | 2 of 5 | 3.3 | -1.3 vs chain |
The other 5 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PHOENIX HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/10/2025 |
| CAIN, LARRY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/29/2004 |
| FORVIS MAZARS LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/10/2025 |
| PHOENIX REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/29/2004 |
| FLOYD, SHANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/14/2010 |
| HERMANCE, TERRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/22/2023 |
| JAY, JUDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/05/2022 |
| MOXLEY, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2024 |
| YOUNG, CATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/24/2009 |
| MIDWEST LAND & INVESTMENT COMPANY | Organization | ADP OF THE SNF | — | since 11/01/2005 |
CMS files one row per role, so the 17 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% 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 $609K 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 2024. 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, FY2024). 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 375396. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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