Highland Park Health Care
1307 R D Miller Drive, Okmulgee, OK 74447 · For profit - Limited Liability company · 114 certified beds · (918) 756-5611 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2025
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,901 in federal fines (most recent 2025-03-31)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 | 10.6% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.6% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.7% | 3.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.6% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.7% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.4% | 25.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 4.7% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 12.4% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.1% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.8% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 97.1% | 74.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.9% | 27.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 20.4% | 16.6% | 12.0% | 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.
48.6% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.6% 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 33 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% 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 | 48.6%CMS range 35.7–62.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.0–15.9 | 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 | 57.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.2% | 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 | 8.9% | 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 | 6.6%CMS range 3.1–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 114 beds and averages 75.5 residents a day — about 66% occupied, or roughly 38 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.12 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 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 3.25 hrs/resident/day on weekends vs 3.75 on weekdays — 13% thinner on weekends. RN hours go from 0.12 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · J2025-03-31 · 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
A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 03/20/25 related to the facility's failure to ensure Resident #1 was not physically or psychosocially abused. On 03/26/25, the Oklahoma State Department of Health was notified and verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents were not physically or psychosocially abused. The past noncompliance IJ was removed effective 03/20/25 after the facility performed one on one inservices for all staff regarding abuse on 03/20/25. On 03/20/25 employee #1 was suspended then terminated on 03/25/25. On 03/20/25 at 3:26 p.m., a quality assurance meeting was held via conference call. Based on record review and interview, the facility failed to ensure a resident was not physically or psychosocially abused for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 81 residents resided in the facility. Findings: A policy titled Abuse, Neglect and Exploitation and Misappropriations of Resident Property. dated 06/23/17, read in part,…
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 · Fcited before2026-06-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 facility policy review, facility document review, observation, and interview, the facility failed to ensure food was labeled appropriately and failed to ensure leftovers were discarded according to the facility's procedures. The failures had the potential to affect all of the residents who received nourishment from the kitchen.Findings included: A facility policy titled, Food Storage, revised 02/06/2024, indicated, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. The policy revealed, 2. Refrigerator, which included, All foods are covered, labeled and dated. A facility policy titled, Nutrition/Dietary Services, revised 01/16/2025, indicated, The staff will utilize the Nutrition Services Guidelines and standard practice guidelines. The policy revealed the Procedure included C. Food must be obtained from sources that comply with all laws relating to food and food labeling. If food, subject to spoilage, is removed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, facility document review, record review, observation, and interview, the facility failed to ensure a resident's right of a dignified existence for 1 (Resident #7) of 1 resident reviewed for dignity issues. Specifically, the staff failed to ensure a urinary catheter drainage bag was covered in order to protect the resident's dignity. Findings included: A facility policy titled, Resident Rights, revised 08/14/2022, indicated, The staff will abide by and protect resident rights in accordance with state and federal guidelines. An undated facility document titled, [Name of the facility] Resident & Family Handbook indicated, 6. Every resident shall receive respect and privacy in the medical care program of the resident. Case discussion, consultation, examination and treatment shall remain confidential andshall be conducted discreetly. The document further indicated, 11. Every resident shall have the right to receive courteous and respectful care and treatment and a written statement of the services provided by the facility, including those required to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-19 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to communicate with one resident prior to changing the resident's code status (designation to indicate life-saving interventions) for 1 (Resident #3) of twenty-two residents reviewed for advance directives. Specifically, the Director of Nursing (DON) changed Resident #3's code status to DNR (Do Not Resuscitate) without consulting with the resident. Findings included: A facility policy titled, Advanced Directives, revised 02/12/2022, in the section, Advanced Care Planning indicated, 1) In order for the resident to exercise his or her right to make informed choices about care and treatment in preparation for a time when the resident may not be able to make decisions, designated personnel and/or physician will assist with defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, in a language that the resident can understand, as appropriate. A Record of Admission revealed the facility admitted Resident #3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 facility policy review, record review, observation, and interview, the facility failed to develop/implement a comprehensive person-centered care plan addressing a respiratory condition or the use of a nebulizer breathing treatment for 1 (Resident #72) of 1 resident reviewed for respiratory care.Findings included: A facility policy titled, Care Plan-Process, last reviewed 03/27/2023, indicated, The interdisciplinary teal will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required timeframes. The policy revealed, 4. Interdisciplinary Team meets & reviews the care plan as follows, which included With any change of condition. The policy revealed, 6. The Plan of Care identifies the, which included Problem; Goals, measurable and realistic; Interventions, discipline specific services, and frequency; and Resolution/Goal analysis. A Record of Admission revealed the facility admitted Resident #72 on 03/11/2024. According to the Record of Admission, 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 before2026-06-19 · 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, interview, record review, and facility policy review, the facility failed to ensure a resident in a memory care unit was supervised during a nebulizer treatment (the delivery of medication directly to the lungs) for 1 (Resident #72) of 5 residents reviewed for accidents. Findings included:A facility policy titled, Medication Administration Nebulizers, dated 01/2023, indicated, Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer.A Record of Admission revealed the facility admitted Resident #72 on 03/11/2024. According to the Record of Admission, the resident had a medical history that included diagnoses of unspecified dementia and unspecified lack of coordination. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2026, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment. Resident #72's Plan of Care-Current, did not include a focus area for nebulizer use or care, treatment…
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 before2026-06-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, manufacturer instructions review, record review, observation, and interview, the facility failed to ensure the medication administration error rate was less than 5 percent (%). The facility had 2 medication errors out of 31 opportunities, resulting in a medication error rate of 6.45%, which affected 1 (Residents #2) of 5 residents reviewed during the medication administration task.Findings included: A facility policy titled, Medication Administration General Guidelines, dated 01/2024, indicated, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The policy further indicated, Medication Administration included 1. Medications are administered in accordance with written orders of the prescriber. A Record of Admission, indicated the facility admitted Resident #2 on 01/29/2025. According to the Record of Admission, the resident had a medical history that included a diagnosis of type 1 diabetes mellitus (the body's inability 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 · D2026-06-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure an accurate code status was reflected throughout the medical record for 1 (Resident #3) of 22 residents reviewed for advance directives.Findings included: A facility policy titled, Advanced Directives, revised 02/12/2022, indicated, 5) Resident wishes will be communicated to the staff via the care plan.6) The resident's physician will be notified of the resident's advance directive decisions.7) During the quarterly Resident Assessment Instrument (RAI) process and with any significant changes of condition, facility staff will:a) Identify, clarify and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directiveb) Define and clarify medical issue, review the resident's condition and existing choices and present information regarding relevant health care issues to the resident or resident representative as appropriate to determine continuation or modification of choices of care, ande) Changes to 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.
- Potential for harm · D2026-06-19 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, facility document review, a review of a sit-to-stand mechanical lift manufacturer's manual, observation, and interview, the facility failed to ensure 1 of 3 mechanical lifts at the facility were maintained in safe working condition and stored according to manufacturer instructions.Findings included: An undated policy titled, Maintenance Service, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy revealed, 1. The maintenance department is responsible for maintaining buildings, grounds, and equipment in a safe and operable manner at all times. An undated facility document titled, Emergency Procedures Lock-Out/Tag-Out revealed, Goal is to 'lock-out' machinery and equipment from its power source prior to maintenance to avoid accidents that occur from start-up or release of stored energy. The document revealed, Lock-out devices and tags should only be removed by the person who applied them or the person servicing them. The Owner's Operator and Maintenance Manual for the facility's sit-to-stand…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-23 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to: a. store clean dishware inverted and on sanitary surfaces, b. maintain a clean and sanitary kitchen, and c. label, date, and cover food items in the refrigerators during one of two kitchen observations. The DON identified 77 residents received nutrition from the kitchen. Findings: The facility's Employee Infection Control policy, dated 08/01/18, read in part, All local, state, and federal standards and regulations are followed to ensure a safe and sanitary Nutrition Services Department. The policy also read, Store clean dishes inverted or in enclosed or covered storage units. The facility's Food Storage policy, dated 08/01/18, read in part, All foods are covered, labeled and dated. Defrosting meat, eggs, and milk shakes are labeled with date pulled for thawing. The facility's Use of Left Overs policy, dated 08/01/18, read in part, Leftovers should be covered, labeled, dated and stored appropriately. On 08/20/24 at 7:00 a.m., the Initial tour of the kitchen was conducted. The following observations were made…
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 · D2024-08-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to notify the physician for out of parameters blood sugars for one (#41) of two sampled residents reviewed for insulin. The DON identified 31 residents who received insulin. Findings: The Bedside Blood Glucose Monitoring policy, revised on 02/12/20, read in part, If the glucose level is out of the established ranges ordered by the physician .The physician is contacted. Res #41 had diagnoses which included diabetes. The June physician's orders documented the physician was to be called for a blood sugar greater than 350. On the following dates in June, Res #41's blood sugar was above 350 with no documentation the physician was notified. 06/02/24 at 11:00 a.m., the blood sugar was 420. 06/10/24 at 11:00 a.m., the blood sugar was 368. 06/20/24 at 4:00 p.m., the blood sugar was 379. 06/24/24 at 11:00 a.m., the blood sugar was 484. 06/26/24 at 11:00 a.m. the blood sugar was 361. 06/28/24 at 4:00 p.m., the blood sugar was 544. The July physician's orders documented the physician was to be called for a blood sugar greater than 350…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2024-08-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a psychotropic medication was used for a specific diagnosis for one (#71) of five residents who were reviewed for unnecessary medication. The DON identified 15 residents who received psychotropic medication. Findings: Resident #71 had diagnoses which included dementia without psychotic disturbance, cerebrovascular disease, and major depressive disorder. A physician order, dated 02/08/24, documented the resident received olanzapine 10 mg tablet one time a day at bedtime for major depressive disorder without psychotic features. A quarterly assessment, dated 05/22/24, documented the resident was receiving an antipsychotic medication. The assessment documented no potential indicators of psychosis or behaviors. On 08/20/24 at 9:33 a.m., the resident was in bed eating breakfast. The resident was calm and pleasant. The care plan, dated 03/01/24, documented psychotropic drug use. The care plan documented the staff was to monitor for resident behaviors and side effects of the medication every shift and document. On 08/22/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-25 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued ABN and NOMNC notices for two (#38 and #45) of three residents reviewed for beneficiary notices. The facility identified 22 residents who were discharged from part A skilled services with benefit days remaining in the previous six months. Findings: 1. Res #38 was discharged from skilled services on 06/20/23 and remained in the facility. 2. Res #45 was admitted to part A skilled services on 04/06/23, discharged from skilled services on 04/27/23, and remained in the facility. On 07/25/23, the DON was asked to provide ABN and NOMNC notices for Res #38 and Res #45. On 07/25/23 at 4:40 p.m., the administrator stated the facility was unable to provide documentation the ABN or NOMNC notices were provided to Res #38 and Res #45.
- Potential for harm · E2023-07-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to notify the physician related to resident oxygen needs and titrating oxygen without a physician order for one (#125) and failed to provide oxygen as ordered by the physician order for one (#22) of three sampled residents reviewed for oxygen therapy. The DON identified 13 residents with orders for oxygen. Findings: 1. Res #125 was admitted on [DATE] with diagnoses which included post COVID-19 condition, COPD, congested heart failure, atrial fibrillation, chronic hypoxic and hypercapnic respiratory failure, critical illness myopathy, chronic interstitial lung disease, O2 dependent, and history of lung cancer. A physician order, dated 07/07/23, documented to administer O2 6 lpm per nasal cannula for chronic diastolic heart failure. A nurse note by RN #1, dated 07/07/23, documented upon taking report for Res #125, was advised that the resident desaturated quickly with any transfers or movement. The note documented that during a transfer of 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 · E2023-07-25 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the physician responded to pharmacist MRRs in a timely manner for four (#11, 22, 33, and #66) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/17/23, documented 73 residents resided in the facility. Findings: A Medication Regimen Review and Reporting policy, dated January 2023, read in part .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days . 1. Res #66 had diagnoses which included dementia, Alzheimer's disease, and anxiety. A physician order, dated 02/06/23, documented to administer buspirone 5 mg three times daily for anxiety. A MRR, dated 05/22/23, documented a request for a GDR on Res #66's buspirone. There was no documented response to the 05/22/23 GDR request. A MRR, dated 06/21/23, documented a request for a GDR on Res #66's buspirone. The MRR documented the recommendation status as Pending from the previous month's…
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 · E2023-07-25 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a gradual dose reduction of a medication was considered or attempted in a timely manner for two (#33 and #22) and signs and symptoms were present before antibiotic use for one (#34) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/17/23, documented 73 residents resided in the facility and seven residents received antibiotics. Findings: An Antibiotic Stewardship & Antibiotic Prescribing policy, dated December 2022, read in part .Providers will utilize the McGeer's Criteria when considering initiation of antibiotics .Surveillance definitions of skin and soft tissue infections: One of the following criteria must be met: a. Pus present at the wound, skin or soft tissue site b. The resident must have four or more of the following signs or symptoms: fever (100.4 F) or worsening mental/functional status, heat, redness, swelling, tenderness/pain, and/or serous drainage . A Medication Regimen Review and Reporting policy, dated January 2023, read in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-25 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure residents who received psychotropic medications received gradual dose reductions in a timely manner for four (#11, 22, 33, and #66) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/17/23, documented 63 residents received psychoactive medications. Findings: 1. Res #66 had diagnoses which included dementia, Alzheimer's disease, and anxiety. A physician order, dated 02/06/23, documented to administer buspirone (an anxiolytic medication) 5 mg three times daily for anxiety. A care plan, dated 02/06/23, documented a goal for the resident to be free of any discomfort or adverse reactions of buspirone with an intervention to ask the physician to review medication for possible dose reduction every three months. A quarterly assessment, dated 05/09/23, documented the resident had severe cognitive impairment, minimal depression, and received antianxiety medications. A MRR, dated 05/22/23, documented a request for a GDR on Res #66's buspirone. There…
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 before2023-07-25 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 28 opportunities were observed with nine errors. Total medication error rate was 32.14%. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: 1. Res #6's physician order, dated 03/01/22, documented to administer metformin 500 mg with meals for diabetes at 5:00 p.m. On 07/25/23 at 3:06 p.m., CMA #2 was observed administering the metformin to the resident. 2. Res #36's physician order, dated 10/14/21, documented to administer metformin 500 mg with meals for diabetes at 5:00 p.m. On 07/25/23 at 3:13 p.m., CMA #2 was observed administering the metformin to the resident. 3. Res #15's physician order, dated 04/28/23, documented divalproex 250 mg, delayed release, for depression at 5:00 p.m. On 07/25/23 at 3:25 p.m., CMA #2 was observed administering the divalproex to the resident. 4. Res #22's physician order documented to administer carvedilol 3.125 mg for hypertension at 5:00 p.m. On 07/25/23…
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 · D2023-07-25 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to notify the OHCA of a new possible serious mental disorder diagnosis for one (#44) of four sampled residents reviewed for PASARR assessments. The Resident Census and Census and Conditions of Residents report, dated 07/17/23, documented 73 residents resided in the facility. Findings: A Level I PASARR, dated 04/06/22, documented Res #44 did not have a serious mental illness. On 12/26/22, Res #44 received a new diagnoses of delusional disorders and unspecified psychosis not due to a substance or known physiological condition. There was no documentation the OHCA had been contacted to see if a Level II PASARR was required. On 07/24/23 at 2:00 p.m., the MDS coordinator was asked to provide documentation the OHCA was notified when Res #44 had new diagnoses of delusional disorders and unspecified psychosis not due to a substance or known physiological condition to see if a Level II PASARR was required. On 07/24/23 at 3:07 p.m., the MDS coordinator stated the facility did not contact the OHCA but should have.
- Potential for harm · D2023-07-25 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure baseline care plans were completed within 48 hours for one (#22) of 18 sampled residents. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: Res #22 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar disorder, hypertension, and dysphagia. The resident's record did not documented the baseline care plan was completed.
- Potential for harm · Dcited before2023-07-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 — the official record, unedited, may be distressing
Based on record review and interview, it was determined the facility failed to ensure a comprehensive care plan was developed for respiratory therapy for one (#22) of three sampled residents whose care plans were reviewed for oxygen therapy. The Resident Census and Conditions of Residents form documented 18 residents received respiratory therapy. Findings: Res #22 was admitted to the facility with diagnoses of acute and chronic respiratory failure with hypoxia, hypertension, and anxiety disorder. A physician order, dated 02/12/23, documented oxygen at 2 lpm via NC to maintain SpO2 above 92%. An admission assessment, dated 02/16/23, documented the resident required oxygen therapy. A care plan, dated 05/22/23, contained no documentation related to oxygen therapy. On 07/25/23 at 11:45 a.m., the ADON report the care plan should have contained documentation for oxygen therapy.
- Potential for harm · D2023-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to ensure weekly weights were obtained per physician order for one (#20) of three sampled residents reviewed for weights. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: Res #20 was admitted to the facility with diagnoses of anemia, diabetes, and depression. A physician order, dated 03/27/23, documented to obtain weekly weights every Monday morning. On 07/24/23 at 9:56 a.m., a review of the resident's record contained no documented weight for the weeks of June 18th -24th, 2023; June 25th-July 1st, 2023; and July 9th - July 15th, 2023. On 07/25/23 at 11:30 a.m., the ADON reported the resident should have been weighed weekly.
- Potential for harm · Dcited before2023-07-25 · 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 Based on record review and interview, the facility failed to ensure a resident was transported from the hospital in the safest possible way for one (#125) of two residents sampled for hospitalizations. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: Res #125 was admitted on [DATE] with diagnoses which included post COVID-19 condition, COPD, congested heart failure, atrial fibrillation, chronic hypoxic and hypercapnic respiratory failure, critical illness myopathy, chronic interstitial lung disease, O2 dependent, and history of lung cancer. A nurse note by LPN #1, dated 07/09/23, on the evening shift, documented the resident was sent to the ER r/t decreased oxygen saturation. The note documented they did not have a concentrator to deliver oxygen at 10 lpm. The concentrator had not been delivered yet. The note stated they were running low on oxygen tanks so the resident was sent out. The concentrator was delivered approximately two hours later along…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-25 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: On 07/19/23 at 9:00 a.m., no nurse staffing information was posted. On 07/20/23 at 8:30 a.m., no nurse staffing information was posted. On 07/24/23 at 8:45 a.m., no nurse staffing information was posted. On 07/25/23 at 8:30 a.m., no nurse staffing information was posted. On 07/25/23 at 12:00 p.m., the ADON reported the daily nurse staffing information was not posted.
- Potential for harm · D2023-07-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure expired medications and supplies were removed from the medication storage room. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: On 07/25/23 at 2:08 p.m., a tour of the medication storage room for halls #3 & #4 was conducted with CMA #1. The following items were observed. a. one Fluticasone/Salmeterol 250/50 inhale with an expiration date of June 2023, b. eight bulbs of IV Meropenem 1gm with a use by date of 07/17/23, c. three bulbs of IV Vancomycin 1gm with a use by date of 07/21/23, d. five central line kits with an expiration date of 04/30/23, e. two IV start kits with an expiration date of 12/31/22, f. two IV start kits with an expiration date of 01/31/23, g. five culture swab kits with an expiration date of 01/31/23, On 07/25/23 at 2:30 p.m., CMA #1 reported the expired medication and supplies should have already been removed from the medication room. On 07/25/23 at 2:35 p.m., a tour of the medication room for hall #3 was conducted with CMA #2. 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.
- No harm found · Ccited before2026-06-19 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, facility document review, observation, and interview, the facility failed to ensure the daily staff posting information was accurately completed for staff directly responsible for resident care for 17 (06/01/2026 through 06/17/2026) of 17 days reviewed. This had the potential to affect all 74 residents who resided in the facility.Findings included: A facility policy titled, Daily Nurse Staffing Information, revised 01/12/2020, revealed, The CMS [Centers for Medicare and Medicaid Services] required staffing information sheet will be posted in a public area of the nursing facility, as required. The policy revealed, 1. Daily including weekends and holidays, the number of FTEs [full time equivalents] for care staff will be calculated and documented on the facility's Daily Nurse Staffing form. The policy indicated, 2. The facility shall post the following information on a daily basis, which included A. Facility Name; B. Current Date; C. Resident census; and D. The actual hours worked by licensed and unlicensed nursing staff directly responsible for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$14,901 in federal fines across 1 penalty.
- $14,901 — penalty dated 2025-03-31
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to STONEGATE SENIOR LIVING — 24 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 3 of 5 | 3.8 | -0.8 vs chain |
The other 23 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PF HPM SNF OPS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 11/01/2020 |
| SANCTUARY LTC, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/23/2021 |
| PRESERVATION FREEHOLD COMPANY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 09/23/2021 |
| UMB BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 09/23/2021 |
| STONEGATE SENIOR LIVING, LP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/22/2022 |
| CHANCE, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2020 |
| EDWARDS, ANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/24/2023 |
| TAYLOR, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/01/2020 |
| CAMPBELL, SCOTT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/12/2025 |
| FISHER, JAMES | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/12/2025 |
| LANGDON, THOMAS | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/21/2025 |
| MCGEHEE, WILLIAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/21/2025 |
| LIFETIME WELLNESS, LTD. | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| MARTUS FINANCIAL SERVICES, INC. | Organization | ADP OF THE SNF | — | since 12/31/2023 |
| PHARMERICA DRUG SYSTEMS LLC | Organization | ADP OF THE SNF | — | since 08/29/2017 |
| REHAB PRO LP | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| BOLDEN, CHARMAINE | Individual | ADP OF THE SNF | — | since 08/20/2025 |
| MCGUIRE, ANGELA | Individual | ADP OF THE SNF | — | since 08/01/2019 |
CMS files one row per role, so the 24 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375486. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-19, 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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