Shawn Manor Nursing Home

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

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.

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

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

49.6% 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 37 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% 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.

Staffing

How full it usually is: this home is certified for 96 beds and averages 53.7 residents a day — about 56% 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 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 3.02 on weekdays — about the same on weekends as weekdays. RN hours go from 0.25 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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 unchanged from the previous inspection. 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.

22 citations, most serious first. The 14 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · H2022-09-09 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Resident #32 had diagnoses which included, dementia, mood disturbance and anxiety. A five day assessment, dated [DATE], read in parts, ~ had severe cognitive impact; ~ inattentive behavior with fluctuations; ~ disorganized thinking, present with fluctuations; and ~ altered level of conciousness, present with fluctuations. A Nurse's Note dated, [DATE] at 9:00 a.m., read in part, .Late Entry: Note Text: DELAYED ENTRY: [Resident #32] was found visiting .[Resident #85] in [Resident #85's] room with the door shut. Informed by nurse it is fine to visit, but the door has to remain open. [Resident #32] shortly returned to .own room where .[Resident #85] followed and closed the door again. When nurse returned to room and opened door .[Resident #85] hands were groping at [Resident #32's ] lap asking why not and [Resident #32] was heard stating no because my pants are too tight. [Resident #32] informed that [Resident #85] is .married .and became upset stating that [Resident #85] lied to [Resident #32] and [Resident #32]…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2022-09-09 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. Resident #32 had diagnoses which included, dementia, mood disturbance and anxiety. A five day assessment, dated [DATE], read in parts, ~ had severe cognitive impact; ~ inattentive behavior with fluctuations; ~ disorganized thinking, present with fluctuations; and ~ altered level of consciousness, present with fluctuations. A Nurse's Note dated, [DATE] at 9:00 a.m., read in part, .Late Entry: Note Text: DELAYED ENTRY: [Resident #32] was found visiting .[Resident #85] in [Resident #85's] room with the door shut. Informed by nurse it is fine to visit, but the door has to remain open. [Resident #32] shortly returned to .own room where .[Resident #85] followed and closed the door again. When nurse returned to room and opened door .[Resident #85] hands were groping at [Resident #32's ] lap asking why not and [Resident #32] was heard stating no because my pants are too tight. [Resident #32] informed that [Resident #85] is .married .and became upset stating that [Resident #85] lied to [Resident #32] and [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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2022-09-09 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to report allegations of abuse and neglect to local law enforcement and OSDH for for four (#85, 25, 32, and #22) of six sampled residents reviewed for abuse. a. Three (#85, 25, and #32) of six sampled residents were identified to be involved with resident to resident sexual encounters, to include touching, petting, and groping. b. One resident (#22) was identified to have physical aggression toward other residents, to include hitting, scratching, and attempting to run into residents while propelling self in hallway. The Resident Census and Condition of Residents identified 34 residents resided in the facility. Findings: The facility's, undated, Abuse and Neglect - Administrative Protocol policy, read in parts, .residents of this facility will be free of abuse, neglect .The facility will implement the following . Reporting .will sent a report to all reporting agencies as required by OSDH guidelines .will send a report to the Oklahoma State Department 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2022-09-09 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  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 provide evidence that allegations of abuse were thoroughly investigated, implement interventions to protect residents from further abuse, and report abuse allegations within the appropriate time frame to OSDH, APS, and Local Law Enforcement. This affected four (#85, 22, 25, and #32) of six sampled residents reviewed for abuse. a. Three residents (#85, 25, and #32) of three sampled residents who were identified to be involved with resident to resident sexual encounters, to include touching, petting, and groping. b. One resident (#22) identified to have physical aggression toward other residents, to include hitting, scratching, and attempting to run into residents while propelling self in hallway. The Resident Census and Condition of Residents identified 34 residents resided in the facility. Findings: The facility's, undated, Abuse and Neglect - Administrative Protocol policy, read in parts, .residents of this facility will be free of abuse, neglect .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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-20 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure assessments were accurately coded for two (#3 and #5) of 13 sampled residents whose assessments were reviewed. The DON identified four residents who were ordered antiplatelet medications and five residents who were ordered anticoagulant medications. Findings: 1. Resident #3 had diagnoses which included heart failure and long term use of anticoagulant medication. Review of the October 2024 medication administration record did not reveal the resident had received an anticoagulant medication. A physician's order, dated 10/11/24, documented the resident was ordered clopidogrel (an antiplatelet medication) 75mg daily. The admission assessment, dated 10/17/24, documented the resident received an anticoagulant medication. The assessment did not indicate an antiplatelet medication had been received. 2. Resident #5 had diagnoses which included atherosclerotic heart disease. A physician's order, dated 06/23/23, documented the resident was ordered clopidogrel 75mg daily. Review of the September 2024 medication administration…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-20 · tag F0801 — isolated
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview, the facility failed to ensure the food service supervisor completed certification as a certified dietary manager within three years of beginning employment per State requirement. The administrator identified 26 residents resided in the facility and 23 residents received services from the kitchen. Findings: The Food Services Manager policy, revised 10/08, read in part, The Food Services Manager is a qualified supervisor licensed by this state. The DM was hired on 11/13/2015. There was no documentation the DM had completed certification as a certified dietary manager. On 11/18/24 at 1:07 p.m., the DM stated they had been in the dietary manager role for 9 years. They stated they completed the dietary manager training, but had not taken the exam for the certification. On 11/19/24 at 10:35 a.m., the administrator stated the DM had been in their role since 2015. They stated the DM did not have their certification.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-20 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interview, the facility failed to adhere to enhanced barrier precautions for: a. one (#9) of one sampled resident reviewed for a urinary catheter; and b. one (#14) of one sampled resident observed for medication administration via peg tube. The administrator identified 26 residents resided in the facility and 11 residents were on enhanced barrier precautions. Findings: An undated ENHANCED BARRIER PRECAUTIONS facility policy, read in part, Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: Device care or use .urinary catheter, feeding tube. 1. Resident #9 had diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms. A physician's order, dated 05/31/24, documented enhanced barrier precautions for an indwelling medical device three times a day for infection control. Resident #9's care plan for EBP, revised 07/22/24 documented the resident was on EBP related to their suprapubic catheter. It documented staff only had to wear gowns and gloves when touching the…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-11-02 · tag F0571 — pattern
  Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed ensure the co-pay charged to a resident account did not exceed the Medicaid payment limit for one (Resident #5) of four resident whose monies were held in the resident trust. The Administrator identified 20 residents who received Medicaid and 17 residents whose monies were held in the facility trust. Findings: Resident #5 had diagnoses which included bipolar disorder and schizophrenia. On 10/31/23 at 3:07 p.m., Resident #5 stated they received $50.00 a month for personal funds. The trust transaction history, dated 11/02/23, documented the resident received $1854.00 per month and paid $112.00 a month for a medical supplement and $1677.00 to the facility as their vendor payment for a total of $1789.00 in payments, leaving the resident with $65.00 per month for their personal funds. On 11/02/23 at 11:50 a.m., the administrator stated residents' who received Medicare and Medicaid would have $75.00 in personal funds after supplement payment and vendor payment. The administrator stated they did not know why Resident #5 only…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-11-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interview, the facility failed to perform range of motion and positioning for one (#12) of one resident whose clinical records were reviewed for range of motion and positioning. The DON identified two residents with orders for range of motion and positioning. Findings: On 10/31/23 at 2:30 p.m., Resident #12 was observed in bed. The resident's left hand was observed with fingers drawn in. There was no positioning device or hand roll positioned within the left hand. On 11/01/23 at 9:04 a.m., Resident #12 was observed in their room. The resident's fingers of their left hand were drawn in. The resident denied the facility provided range of motion and denied the facility used a hand roll or other positioning device to position the fingers of the left hand. On 11/01/23 at 11:15 a.m., Resident #12 was observed in their room. The resident's fingers of their left hand were drawn in and there was no hand roll or other positioning device to position the fingers of the left hand. On 11/01/23 at 2:55 p.m., Resident #12 was observed in their room. 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-11-02 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview, the facility failed to create a water management plan for the prevention of waterborne pathogens for the facility. The Administrator stated 29 residents resided at the facility. Findings: A Legionella Surveillance and Detection policy, revised date 09/23 read in part .Legionellosis outbreaks are generally linked to locations where water is held or accumulates and pathogens can reproduce . On 11/02/23 at 10:20 a.m., the Administrator stated they knew of the requirement for a water management plan and had attended a seminar on the subject, but had not yet begun to develop the plan.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-09-09 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor 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 record review and interviews, the facility failed to ensure residents were offered an opportunity to up-date an advanced directive for two (#1 and #27) of three sampled residents reviewed for advanced directives. The Resident Census and Condition of Residents documented 34 residents resided in the facility with four residents having formulated an advanced directive. Findings: 1. The admission packet, dated 12/01/20, documented Resident #1 did not have an advance directive or living will. The form documented information was offered to formulate an advance directive. The admission packet and information was signed by the resident's representative. The clinical record contained no further information an advance directive was re-assessed/re-offered to ensure Resident #1's wishes were followed at end of life. 2. An admission packet, dated 08/21/19, documented Resident #27 did not have a DNR or advance directive. The form documented information was offered to formulate an advance directive. The admission packet and information was signed by the resident's representative. The…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-09-09 · tag F0641 — pattern
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessment accurately reflected the residents status for two (#1 and #24) of 14 sampled residents. The Resident Census and Condition of Residents identified 34 residents resided in the facility. Findings: A P&P, titled Comprehensive Assessment and the Care Delivery Process, revised December 2016, read in parts, .Comprehensive assessments will be conducted to assist in developing person-centered care plans .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating intervention, and then monitoring results and adjusting interventions . 1. Resident #1 had diagnosis to include centrilobular emphysema, hypertension, arthritis, chronic obstructive pulmonary disease, and dementia. A fall care plan, last updated 02/21/22, read in parts, .at risk for falls r/t dementia .cue me routinely for safety while transferring self .assistance as needed .prompt response to all…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-09-09 · tag F0757 — failed to avoid unnecessary drugs — pattern
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview, the facility failed to ensure monitoring was completed for the effectiveness of a hypnotic medication for one (#25) of one resident reviewed for the administration of a hypnotic medication. The Resident Census and Condition of Residents documented two residents had physician orders for a hypnotic medication to be administered, and the facility census was 34. Findings: Resident #25 had diagnosis to include anxiety disorder, depression, and insomnia. A physician order, dated 07/25/22, documented Resident #25 was to be administered Ramelteon 8 mg every night at bedtime for insomnia. The clinical record did not contain documentation the effectiveness of the hypnotic medication had been monitored. On 09/08/22 at 3:37 p.m., the DON was asked if Resident #25 had been monitored for the effectiveness of Ramelteon that had been administered for insomnia. After review of the record, the DON stated a behavior monitoring order should have been put in place to prompt the monitoring of the effectiveness of the hypnotic medication, but had not been.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-09-09 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview the facility failed to respond in a timely manner to a pharmacists recommendations for a GDR of a psychotropic medication for one (#16) of five sampled residents reviewed for pharmacy recommended GDR's. The Resident Census and Condition of Residents, documented 21 residents received psychotropic medications. Findings: A P&P titled, Tapering Medications and Gradual Dose Reduction, revised 2007, read in parts, .After medications are ordered for the resident, the staff and practitioner shall seek an appropriate dose and duration for each medication .Resident who use antipsychotic drugs shall receive a gradual dose reduction .unless clinically contraindicated .The Physician will review periodically whether current medications are still necessary in their current dose . Resident #16 had diagnoses which included, Insomnia and depressive disorder, recurrent, severe with psychotic symptoms. A physician medication review report, read in parts, .traZODone HCL Tablet 50 MG Give 0.5 tablet [25 mg] by mouth at bedtime for Insomnia .start date 04/28/21…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CONHOLD — 5 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 →

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

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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 82% 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 $275K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK