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The Golden Rule Home

38801 Hardesty Road, Shawnee, OK 74801 · For profit - Corporation · 83 certified beds · (405) 273-7106 Medicare & Medicaid certified

Call the home — (405) 273-7106 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$10,246 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,246 in federal fines (most recent 2023-09-07)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
318 W Highland St · (405) 585-0693 · Call to confirm hours
Pharmacy
19680 Gordon Cooper Dr · (405) 287-3053 · Call to confirm hours
Grocery
1570 Gordon Cooper Dr · (405) 878-4850 · Call to confirm hours
Park
(405) 878-1528 · Typically dawn to dusk
Place of worship
18502 Highway 177 · (405) 275-3038

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.6%13.6%15.4%worse
Long-stay residents who lose too much weight6.4%3.3%5.4%worse
Long-stay residents with a catheter left in their bladder3.1%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.8%2.0%better
Long-stay residents with depressive symptoms0.0%3.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained3.4%0.1%0.1%worse
Long-stay residents with falls causing major injury0.7%4.7%3.3%better
Long-stay residents whose ability to walk worsened19.2%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication28.6%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine97.2%94.6%95.3%typical
Long-stay residents with pressure ulcers4.7%4.7%4.7%typical
Long-stay residents with worsening bladder/bowel control8.8%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table42.7%17.5%17.1%worse
Short-stay residents rehospitalized after admission20.3%27.3%22.6%better
Short-stay residents with an outpatient ER visit3.3%16.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.432.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.602.961.80better

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

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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

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

12.0%U.S. median 10.7%
Went back to hospital
0.07U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.07 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.0%CMS range 7.0–18.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.33
RN hours/ resident / day
0.46
LPN hours/ resident / day
2.12
Aide hours/ resident / day
2.91
Total nurse hours/ resident / day
0.35
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 83 beds and averages 52.5 residents a day — about 63% occupied, or roughly 30 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 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 2.85 hrs/resident/day on weekends vs 2.93 on weekdays — 3% thinner on weekends. RN hours go from 0.32 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

9
deficiencies at the latest standard inspection (2026-06-12)
4
at the previous standard inspection (2024-10-03)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2023-09-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 provide adequate supervision to prevent elopement which resulted in a past noncompliance immediate jeopardy (IJ) situation effective from 05/28/23 to 05/30/23 for one (#15). Res #15 eloped from the facility on 05/24/23 and was found 300 yards away on a county road. The facility put interventions in place up through 05/28/23. The resident eloped again on 05/30/30 and was found in a nearby field. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: Res #15 was admitted to the facility on [DATE] and had diagnoses which included dementia and Parkinson's disease. An Elopement Risk Scale, dated 08/24/22, documented the resident was a high risk to wander. The elopement risk assessment documented the resident Wanders aimlessly within facility or off facility grouns or has a reported history of elopement. There was no care plan initiated at that time. An Elopement Risk Scale, dated 09/12/22, documented…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · F2026-06-12 · tag F0801 — widespread
    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 — an excerpt from the official record, may be distressing

    Based on interview and facility document review, the facility failed to ensure that the designated director of food service met the minimum required qualifications. Specifically, the facility did not employ a full-time Registered Dietitian (RD), and the facility Dietary Manager (DM) was not a certified dietary manager or certified food service manager, nor did she have an associate's degree or higher in food service management. This failed practice had the potential to affect 52 residents who received meals from the kitchen (total census: 56).Findings included: A facility Job Description & [and] Orientation Checklist, dated 07/1998, indicated the Dietary Manager (DM) position required, Bachelor's degree (B.A.) from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience. The job description further indicated the DM, Must hold or be capable of acquiring certificates required by the state. In an interview on 06/08/2026 at 10:14 AM, the DM stated she was not a Certified Dietary Manager (CDM) but was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-06-12 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document and policy review, the facility failed to follow the planned, written menu for 1 of 2 meals observed. Specifically, the facility served incorrect portion sizes for the lunch meal on 06/09/2026. This failure had the potential to affect 52 residents who received meals from the kitchen (total census: 56).Findings included: A facility policy titled Menus, revised 10/2008, indicated Menus shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed. A facility Menu Guide Report for the lunch meal on Tuesday 06/09/2026 indicated the planned menu included 1/3 cup (c.) garlic mashed potatoes and 1/3 c. green peas for regular diets, pureed diets, and mechanical soft diets. The menu also included a #12 (1/3 c.) dipper of pureed meatloaf and a #16 (1/4 c.) dipper of pureed bread for residents on pureed diets. During observations of the lunch meal on 06/09/2026 beginning at 12:05 PM, the Dietary Manager (DM) served the mashed potatoes for all diets and the pureed meat and pureed green peas for pureed diets…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-06-12 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and facility document and policy review, the facility failed to ensure the Medical Director participated in the facility's Quality Assurance and Performance Improvement (QAPI) Committee meetings as required for 13 of 13 reviewed QAPI meetings held during the timeframe from 05/30/2025 through 05/29/2026.Findings included: A facility policy titled. Quality Assurance and Performance Improvement (QAPI) Committee, dated 04/2014, revealed, This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program. The policy specified, 3. The following individuals will serve on the committee: d. Medical Director. Review of QAPI meeting sign-in sheet dated 05/30/2025, 06/30/2025, 07/31/2025, 08/29/2025, 09/30/2025, 10/31/2025, 11/28/2025, 12/29/2025, 01/30/2026, 02/27/2026, 03/31/2026, 04/29/2026, and 05/29/2026 revealed no documented evidence the Medical Director participated in the meetings.During an interview on 06/12/2026 at 1:27 PM, the Administrator reviewed the QAPI meeting…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-12 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed on a quarterly basis and submitted within the required timeframe for 17 (Residents #33, #12, #16, #17, #18, #22, #23, #3, #35, #38, #40, #43, #44, #45, #5, #54, and #8) of 18 residents reviewed for resident assessments. Findings included: A facility policy titled, Resident Assessment Instrument, revised 09/2010, specified, 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: c. at least quarterly. The State Operations Manual Appendix PP guidance at F638 indicated, A Quarterly assessment is considered timely if:- The Assessment Reference Date (ARD) of the Quarterly MDS is within 92 days (ARD of most recent OBRA [Omnibus Budget Reconciliation Act] assessment + [plus] 92 days) after the ARD of the previous OBRA assessment (Quarterly, Admission, Annual, Significant Change in Status, Significant Correction to Prior…

    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 · Ecited before2026-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 observation, interview, record review, and facility policy review, the facility failed to assess smoking safety prior to allowing residents to smoke unsupervised, failed to supervise residents who required supervision with smoking, and failed to ensure residents who smoked did so in accordance with the facility's smoking policy. Failed practices were identified for 3 (Residents #68, #50, and #55) of 3 residents reviewed for smoking. The failed practices had the potential to affect 14 residents who smoked, according to a list provided by the facility. Specifically, the facility failed to:- reassess smoking safety and need for supervision for Resident #68 after the resident was observed in the smoking area with oxygen in use on two occasions;- assess Resident #50 for safety while smoking; and,- provide supervision with smoking to Resident #55, whose assessment indicated they were an unsafe smoker.Findings included: An undated facility policy titled, The Golden Rule Smoking/Vaping Policy indicated, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-12 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 was assessed for the ability to safely self-administer medication and failed to obtain a physician's order prior to allowing the resident to self-administer medication for 1 (Resident #33) of 8 sampled residents reviewed for self-administration of medications.Findings included: A facility policy titled, Administering Medications, revised 04/2010, specified, 18. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do safely. A facility policy titled, Self-Administration of Medications, revised 12/2012, specified, Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-12 · tag F0609 — failed to report abuse allegations — isolated
    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

    Based on interview, record review, and facility document and policy review, the facility failed to ensure a certified nursing assistant (CNA) immediately reported an allegation of suspected abuse in a manner consistent with the process outlined in the facility's abuse policy for an incident involving 1 (Resident #20) of 4 sampled residents reviewed for abuse. Specifically, CNA #11 notified the off-duty Assistant Director of Nursing (ADON) of suspected abuse by way of text message instead of notifying a supervisor on-duty or the facility's Abuse Coordinator directly as specified in the facility's abuse policy, which resulted in a delayed initial report submission to the state survey agency (SSA).Findings included: An undated facility policy titled, Abuse and Neglect Prohibition Program, Section 3, revealed, When abuse, neglect, mistreatment, or misappropriation of personal property of a resident is observed, or suspected, staff must immediately notify their supervisor on duty, who, in turn, should notify the abuse coordinator/administrator and director of nursing services. The policy…

    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 · D2026-06-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, medical record review, and facility policy review, the facility failed to ensure medication administration was accurately documented in the medical record for 1 (Resident #73) of 22 residents whose medical records were reviewed.Findings included: A facility policy titled, Charting Errors and/or Omissions, revised 12/2006, indicated, Accurate medical records shall be maintained by this facility. An admission Summary for Resident #73 revealed the facility admitted Resident #73 on 06/12/2023. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2025, revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #73 had diagnoses that included dementia, anxiety, and respiratory failure. The MDS indicated Resident #73 had shortness of breath with exertion and when lying flat. Resident #73's Monthly Orders Sheets for February 2025 indicated Resident #73 had a physician's order dated 06/28/2023 for Ventolin hydrofluoroalkane (HFA)…

    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 · D2026-06-12 · 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, interview, record review, and facility document and policy review, the facility failed to ensure the proper storage of respiratory equipment for 1 (Resident #33) of 2 sampled residents reviewed for respiratory care, and failed to ensure staff used personal protective equipment (PPE) during the care of a resident on Enhanced Barrier Precautions (EBPs) for 1 (Resident #7) of 1 sampled resident reviewed for EBP. Specifically, Resident #33's nebulizer mouthpiece was not stored in a bag or closed container when not in use to prevent potential contamination, and staff performed wound and incontinence care for Resident #7 without donning the appropriate PPE.Findings included: 1. A facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, specified, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medications into the resident's airway. The Steps in the Procedure indicated that after administering the treatment, staff should, 27. Rinse and disinfect the nebulizer…

    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 · E2024-10-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were offered the right to formulate an advance directive for two (#24 and #25) of three sampled residents reviewed for advance directives. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/01/24, documented 36 residents resided in the facility. Findings: An Advance Directive policy, dated April 2008, read in part, .upon admission to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care .and the right to formulate advance directives . 1. Resident #24 admitted to the facility on [DATE]. Resident #24's medical record did not contain an advanced directive or an advance directive acknowledgement form. 2. Resident #25 admitted to the facility on [DATE]. Resident #25's medical record did not contain an advanced directive or an advance directive acknowledgement form. On 10/01/24 at 1:47 p.m., the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Ecited before2024-10-03 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure careplans were updated quarterly for three (#14, 26, and #27) of 14 sampled residents reviewed for careplans. The DON identified 34 residents resided in the facility. Findings: A Care Plans policy, dated October 2010, read in part, .care plan that includes measurable objectives and timetables to meet the resident's .needs .The comprehensive care plan is based on a thorough assessment that includes .the MDS .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .At least quarterly . 1. Resident #14 had diagnoses which included depression and anxiety. A care plan, dated 12/11/23, did not contain quarterly updates. Resident #14 had a comprehensive resident assessment, dated 12/12/23. 2. Resident #26 had diagnoses which included acute kidney failure, cerebral infarction, bipolar, COPD, and HTN. A care plan, dated 11/20/23, did not contain quarterly updates. Resident #26 had comprehensive resident assessments dated 05/25/24 and 08/25/24. 3. Resident #27 had diagnoses which…

    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 · D2024-10-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to conduct thorough skin assessments weekly for one (#138) of one sampled resident reviewed for non-pressure related skin conditions. The DON identified 34 residents resided in the facility. Findings: A Pressure Ulcer Risk Assessment form, dated September 2013, read in part, .Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis .Documentation .The conditions of the resident's skin . Res #138 admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, neuropathy, and gout. A physician order, dated 09/16/24, documented to complete a skin assessment weekly on the 7-3 shift on Mondays. A Weekly Wound Assessment form, documented Res #138 refused a skin assessment on 09/16/24. On 09/17/24 at 2:00 p.m., LPN #1 documented a head to toe skin assessment was completed. The note did not document the presence of dressings to the heels. On 09/30/24 at 10:29 a.m., Res #138…

    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 · D2024-10-03 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure dietary staff properly utilized hair nets for one (Cook #1) of three sampled employees observed for kitchen sanitation. The DON identified 34 residents resided in the facility. Findings: On 09/30/24 at 9:14 a.m., [NAME] #1 was observed preparing the noon meal. They were observed to have hair outside of their hairnet around their ears and a ponytail in the back. On 09/30/24 at 9:17 a.m., the DM was asked what was the policy for hair nets. They stated everyone should have one on and we all have them on. The DM was asked to observe [NAME] #1 and asked if all of their hair was secured in their hair net. The DM stated, No, not around [Cook #1's] hair. The DM was informed [NAME] #1's ponytail was not secured in the hair net.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to: a) turn and reposition a resident with pressure ulcers for one (Res #2) of three sampled residents reviewed for pressure ulcers, b) obtain orders for treatment of pressure ulcers upon admission for one (Res #2) of three sampled residents reviewed for pressure ulcers, and c) complete weekly wound assessments for one (Res #3) of three sampled residents reviewed for pressure ulcers. The ED identified 36 residents resided in the facility. Findings: 1. A facility repositioning policy, revised April 2013, documented a resident in bed should be repositioned at least every two hours, and a resident with a stage one or higher pressure ulcer may require more frequent repositioning. The policy documented the information recorded in the resident's record should include the position in which the resident was placed, the name and title of the individual who gave the care, and if the resident refused, why. Res #2 admitted to the facility on [DATE] with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 provide hydration to a resident each shift for one (Res #2) of three residents reviewed for hydration and nutrition. The ED identified 36 residents resided in the facility. Findings: Res #2 admitted to the facility on [DATE] with diagnoses which included hypotension and acute kidney failure. A review of meal percentage records and intake and output records for May 2024 documented Res #2 did not receive hydration 13 of 69 opportunities. A review of meal percentage records and intake and output records for June 2024 documented Res #2 did not receive hydration two out of 90 opportunities. A review of intake and output records for July 2024 documented Res #2 did not receive hydration seven out of 51 opportunities. On 08/13/24 at 3:19 p.m., the ADON stated hydration and ice are passed to the residents three times per day, once on each shift. They stated they did not know why there were blanks on Res #2's hydration records.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-07 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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 the pharmacy medication regimen review recommendations in a timely manner and failed to have a policy which included time frames for the different steps in the process for two (#25 and #15) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: A Consultant Pharmacist policy, dated June 2017, read in parts, .Recommendations, plans for implementation, assessments, and any irregularities noted during the consultant's review are compiled into a Drug Regimen Review report .The facility is responsible to assure that the appropriate personnel address these recommendations. The DON is responsible for ensuring the Drug Regimen Reviews are reviewed by the attending physician and medical director . 1. Res #25 had diagnoses which included hypothyroidism, dementia without behavioral disturbance, and major depressive disorder. A physician order, dated 02/18/22, documented 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident who received psychotropic medications received a gradual dose reduction for an antidepressant medication in a timely manner for one (#25) and an acceptable diagnoses/indication for the use of an antipsychotic medication for one (#15) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, documented 22 residents received psychoactive medications. Findings: A Consultant Pharmacist policy, dated June 2017, read in parts, .Recommendations, plans for implementation, assessments, and any irregularities noted during the consultant's review are compiled into a Drug Regimen Review report .The facility is responsible to assure that the appropriate personnel address these recommendations. The DON is responsible for ensuring the Drug Regimen Reviews are reviewed by the attending physician and medical director . 1. Res #25 had diagnoses which included hypothyroidism, dementia without…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-07 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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% for three (#2, 6, and #14) of eight residents observed during medication pass. A total of 36 opportunities were observed with 21 errors. Total error rate was 58.33%. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: A Medication Administration Procedures policy, undated, documented medication can be administered within a two-hour time frame (one hour before to one hour after the time prescribed by the physician or as established by medications administration time policy). Administering medications too early or too late is considered a medication error. Medications specifically ordered before or after meals must be administered as such or will be considered a medication error. A Medication Administration Times form, updated 05/30/21, documented as follows: a. All orders that have a specific time will be administered as requested. b. Anti-ulcer medications to be administered before meals or at…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · 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 accurate coding of MDS assessments for indwelling catheters and anticoagulant use for two (#3 and #10) of 16 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: 1. Res #3 had diagnoses which included anoxic brain damage, gastroparesis, and diabetes insipidus. An annual assessment, dated 01/17/23, documented the resident was severely cognitively impaired, required total assistance with toileting, and had an indwelling catheter. An quarterly assessment, dated 04/17/23, documented the resident was severely cognitively impaired, required total assistance with toileting, and had an indwelling catheter. An quarterly assessment, dated 07/17/23, documented the resident was severely cognitively impaired, required total assistance with toileting, and had an indwelling catheter. Res #3's records were reviewed and did not document an order for an indwelling catheter during the review periods. On 09/05/23 at 8:19 a.m., the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0644 — isolated
    Coordinate 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 refer a resident with a new serious mental illness to OHCA for a level II evaluation for one (#11) of one residents sampled for PASRR level II evaluations. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: Res #11 was admitted with diagnoses of senile dementia and anxiety disorder. On 08/14/12 the resident was diagnosed with schizophrenia disorder. There was no documentation the OHCA had been notified of the resident's new diagnosis to see if a level II PASRR was required. On 09/07/23 at 10:57 a.m., Social Service #1 was asked if OHCA had been notified to see if the resident required a level II PASRR. They stated they had not been notified.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 dementia for one (#15) of 16 sampled resident whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: Res #15 was admitted to the facility with diagnoses of diabetes mellitus, dementia, hypertension, anemia, heart failure, and major depressive disorder. A care plan, dated 05/10/23, contained no documentation related to dementia. An admission assessment, dated 06/30/23, documented the resident was severely impaired with cognition. On 09/07/23 at 1:20 p.m., the ADON reported dementia should have been care planned.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure care plans were updated related to accidents for one (#25) of three residents reviewed for accidents. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: Res #25 had diagnoses which included history of falling, dementia without behavioral disturbance, osteoporosis, unsteadiness of feet, CVA, morbid obesity, neuralgia and neuritis. An annual assessment, dated 02/22/23, documented the resident was moderately cognitively impaired, required extensive assistance with most ADLs, and had one fall with no injury. A care plan, dated 05/01/23, documented the resident was at risk for falls due to impaired mobility, medications, and multiple diagnoses. The care plan documented the following interventions: a. One-half bed rails for mobility and assistance in repositioning, b. Assist resident as needed to reposition frequently, c. Check on resident frequently, d. Do not rearrange personal belongings without my knowledge and approval, e. Encourage adequate…

    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 · D2023-09-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to: a. provide nail care for a resident who was unable to carry out activities of daily living for one (#13) of 16 sampled residents. b. provide showers per the plan of care and/or resident preference for one (#18) of three residents sampled for activities of daily living. The Resident Census and Conditions of Residents form documented 31 residents required the assistance of staff with ADLs. Findings: 1. A quarterly assessment, dated 08/02/23, documented the resident required extensive to total assist with all ADL's. The August 2023 TAR documented nail care to be performed weekly on Tuesday on 3-11 shift and both finger nails and toe nails were to be done. On 08/30/23 at 12:11 p.m., the resident was observed in the dining room with no socks on. The resident's toe nails were observed to be long and discolored. On 09/06/23 at 09:45 a.m., this surveyor asked the LPN charge nurse if she could remove the resident's socks so the resident's toe nails could be observed. The resident's toe nails were long and discolored.…

    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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$10,246 in federal fines across 1 penalty.

  • $10,246 — penalty dated 2023-09-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
DAVES, WILLIAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE100%since 03/31/2017
DAVES, CASEYIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 03/31/2017

CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$3.3M
Net patient revenuemost recent cost report
-27.8%
Operating marginrevenue minus expenses
$573K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 9%Other / private 10%

About 81% 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 $573K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$321per resident / day
operating cost
$9,761per month
≈ monthly operating cost
$251per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.

Typical monthly cost in Oklahoma
$7,026/mo
Nursing home (semi-private)
$7,756/mo
Nursing home (private)
$6,150/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375513. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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