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Stigler Nursing & Rehab

1402 Northwest 7th Street, Stigler, OK 74462 · For profit - Limited Liability company · 80 certified beds · (918) 967-3381 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 2024Behavioral-health or dementia-care citation — no harm found (F0758)3 immediate-jeopardy citations$66,206 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
  • 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 cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $66,206 in federal fines (most recent 2024-08-01)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
907 NW 5th St · (918) 967-3355 · Call to confirm hours
Pharmacy
501 NW H St · (918) 967-8877 · Call to confirm hours
Grocery
208 W Main St · (918) 967-2671 · Call to confirm hours
Park
Roye Park0.3 mi
1215 NW 10th St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
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 increased11.5%13.6%15.4%better
Long-stay residents who lose too much weight0.7%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.9%1.9%0.9%typical
Long-stay residents with a urinary tract infection1.0%2.8%2.0%better
Long-stay residents with depressive symptoms5.8%3.4%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.0%4.7%3.3%better
Long-stay residents whose ability to walk worsened11.9%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication29.0%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine96.2%94.6%95.3%typical
Long-stay residents with pressure ulcers5.2%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control16.1%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.5%17.5%17.1%better
Long-stay hospitalizations per 1,000 resident days2.832.311.67worse
Long-stay outpatient ER visits per 1,000 resident days3.232.961.80worse

§ 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.

11.0%U.S. median 10.7%
Went back to hospital
0.16U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% 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 SNF11.0%CMS range 6.8–17.610.7%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 SNFs1.141.02Oct 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

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
60.0%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 80 beds and averages 54.0 residents a day — about 68% occupied, or roughly 26 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.

Weekend coverage: total nurse staffing is 3.64 hrs/resident/day on weekends vs 4.30 on weekdays — 15% thinner on weekends. RN hours go from 0.15 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

5
deficiencies at the latest standard inspection (2026-02-12)
1
at the previous standard inspection (2024-04-17)

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.

23 citations, most serious first. The 14 most serious are shown; the remaining 9 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-08-01 · 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 On 07/31/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #1, who was at risk for elopement, did not elope from the facility. Res #1 admitted to the facility on [DATE] with diagnoses including dementia. Res #1 eloped from the facility on 06/29/24 without staff knowledge and was returned to the facility by a community member. The facility did not complete one-on-one monitoring upon the Res #1's return or initiate environmental interventions for prevention. The care plan was not revised for the Res #1 and staff did not have a consistent plan to monitor and prevent elopement for the resident. On 07/31/24 at 3:00 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to elopement for Res #1. On 07/31/24 at 3:12 p.m., the administrator was notified of the IJ situation. On 08/01/24 at 12:11 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2023-03-01 · tag F0678 — failed to provide CPR when needed — pattern
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff were available 24 hours a day who had current certification in CPR for Healthcare Providers (training to include hands-on practice and in-person skills) and maintain their certifications to be able to provide CPR until emergency medical services arrived. The facility failed to have a CPR policy and ensure staff were familiar with facility policies related to CPR. Three of the facility's 15 nurses had CPR certification, one night shift nurse who worked three shifts a week, one weekend nurse, who worked the day shift, and the administrator/RN, who was not on the schedule. No CMAs or CNAs had evidence of CPR certification. On [DATE] at 3:35 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. On [DATE] at 3:41 p.m., the administrator was notified of the IJ situation. On [DATE] at 12:14 p.m., an acceptable plan of removal was submitted to the Oklahoma State…

    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
  • Immediate jeopardy · Kcited before2023-03-01 · 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

    On 02/28/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; monitor and evaluate the effectiveness of the interventions; modify the care plan with each fall; conduct a root cause analyses for each fall; and communicate the interventions with all staff. Res #41 had 16 falls in four months with one fall resulting in a fractured hip. Res #41 had sustained a broken hip after six falls and only two falls had steps to prevent recurrence. Res #41 had nine falls after a hip fracture with only two of those falls having interventions to prevent recurrence. The last fall was 02/26/23. Res #24 had five falls in four months, with the forth fall resulting in a fractured hip. Res #34 had eight falls in the last four months with the last fall resulting in a 17 x 2 cm skin tear to arm. The facility failed to consistently put interventions in place to prevent falls for these residents. On 02/28/23 at 1:59 p.m., the Oklahoma State Department of Health…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-02-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    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 Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#1) of four residents sampled for abuse. On 08/06/23 CNA #1 sprayed Res #1 in the face for five seconds while the resident was screaming, yelled at the resident, and then sprayed her in the face again again per witness statement and interview. CNA #1 was terminated for abuse on 08/06/23 and rehired on 09/21/23. The administrator identified 58 residents residing in the facility. Findings: A document titled, [NAME] County Nursing Center, dated 01/11/23, signed by CNA #1, read in part, .Abuse/Incident Reporting/Investigations What is reportable and actions to be taken: 1. Abuse is defined in many ways in the nursing home setting. Abuse can be physical, emotional, mental, verbal, and sexual .4. The most important thing you do is make sure all residents are safe and notify your DON, ADON, and/or Administrator . Res #1 had diagnoses which included dementia, major depression disorder, anxiety disorder, and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-02-12 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a RN was in the facility 08/2025 through 09/2025 at least eight consecutive hours a day, seven days a week.The administrator identified 54 residents resided in the facility. Findings: A PBJ [Payroll Based Journal] Staffing Data Report, dated 07/01/25 through 09/30/25, showed no RN hours on 08/25/25, 09/19/25, 09/24/25, and 09/25/25. A form titled DON TIME LOG, dated 08/2025, did not show the DON worked on 08/25/25. The DON stated they were considered the eight hour a day RN coverage Monday through Friday for the facility. A form titled DON TIME LOG, dated 09/2025, did not show the DON worked on 09/19/25, 09/24/25, or 09/25/25. The DON stated they were considered the eight hour a day RN coverage Monday through Friday for the facility. A nurse staff schedule for 02/2026 showed the DON was considered the eight hour a day consecutive RN coverage for the facility Monday through Friday. On 02/11/26 at 2:22 p.m., the DON reviewed the DON time log and stated they must have failed to sign the log when they worked on…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · tag F0578 — failed to honor advance directives / code status — isolated
    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 provided with advance directive information for 2 (#5 and #10) of 24 sampled residents reviewed for advance directives.The administrator identified 54 residents resided in the facility.Findings: A facility policy titled Health, Medical Condition and Treatment Options, Information Resident of, dated 12/2022, read in part, Residents will be informed of their health, medical condition and options for treatment and/or care.Right to formulate an advance directive upon admission and/or if the resident requests to complete an advance directive after admission. 1. A physician order tab in the electronic medical record showed Resident #5 was admitted to the facility on [DATE]. A review of the electronic health records for Resident #5 showed no advanced directive acknowledgement form. A physician order for Resident #5, dated 02/04/26, showed the resident's code status was do not resuscitate. On 02/11/26 at 1:30 p.m., the administrator…

    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 · Dcited before2026-02-12 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure residents who were discharged from Medicare Part A skilled services, had benefit days remaining, and remained in the facility were issued SNF ABN and NOMNC notices for 1 (#23) of 3 sampled residents reviewed for beneficiary notices. The MDS coordinator identified nine residents discharged from Medicare Part A skilled services with benefit days remaining in the past six months. Findings:A ''SNF Beneficiary Notification Review form, dated 02/10/26, showed Resident #23 was admitted to Part A skilled services on 10/23/25, discharged from Part A skilled services on 12/19/26, and remained in the facility. The form showed Resident #23 was not provided with a SNF ABN or NOMNC notice.On 02/10/26 at 12:55 p.m., the MDS coordinator stated SNF ABN and NOMNC notices were not provided to Resident #23 but should have been per regulations.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · 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 — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure staff served food in a manner that would reduce the risk of cross contamination during one of one kitchen observation. The DM identified 53 residents received meals prepared by the kitchen and one resident who received nutrition via peg tube. Findings: On 02/11/26 at 12:00 p.m., meal service was observed. CNA #1 approached the kitchen window to obtain a meal prepared by the dietary staff. The dietary staff prepared a plate, desert dish, and drinks for the staff to transport to a resident's table. CNA #1 picked up the uncovered meal plate and the desert dish in each hand. There were two drink glasses remaining to be transported. CNA #1 picked up the glasses by the rims using their third, fourth, and fifth fingers of each hand and transported the meal the resident's table. CNA #2 approached the kitchen window to obtain another resident's meal. CNA #2 picked up the uncovered plate and placed the desert dish in the middle of the plate touching the food items. CNA #2 then picked up two drink glasses 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure walls were kept clean for 1 (room [ROOM NUMBER]) of 1 room observed for infection control concerns.The administrator identified 54 residents resided in the facility. Findings: On 02/05/26 at 1:30 p.m., room [ROOM NUMBER] was observed. There was 3 to 4 inches of the base board pulled away from the bottom of the wall next to the bathroom door. There was a moderate amount of a black substance on the wall under and around the base board. On 02/05/26 at 1:40 p.m., housekeeper #1 stated they had worked at the facility for three months. Housekeeper #1 stated the black substance on the wall looked like mold. They stated it had been that way since they have worked at the facility. Housekeeper #1 stated they had tried to clean it off the wall several times, but it would not come off. On 02/11/26 at 10:46 a.m., the maintenance supervisor stated the black substance looked like mold. They stated they used spackling to adhere the base board back to the wall and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-01 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure RN coverage eight consecutive hours seven days per week. The Resident List Report documented 54 residents resided in the facility. Findings: Timecards from 06/16/24 to 07/31/24 documented RN coverage was not provided for eight consecutive hours on: 06/16/24, 06/17/24, 06/28/24, 07/02/24, 07/03/24, 07/04/24, 07/10/24, 07/13/24, 07/17/24, 07/18/24, 07/27/24, and 07/28/24. On 08/01/24 at 1:15 p.m., staff #4 stated there was not a RN in the building on 07/27/24 and 07/28/24. They stated they were unaware the RN on shift was clocking out before a full eight hours was worked.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · 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, the facility failed to ensure a comprehensive care plan was developed for a resident with wounds for one (#1) of three sampled residents whose wound documentation was reviewed. LPN #2 identified ten residents who had wounds. Findings: Res #1 had diagnoses which included paraplegia, end stage renal disease, hepatitis c, diabetes and pressure ulcers. Wound care assessments, dated 05/22/24, documented Res #1 had pressure ulcers to their coccyx, left heel, outer right ankle, outer right foot and spinous process lower. Res #1's comprehensive care plan did not include a care plan for their pressure ulcers. On 05/23/24 at 12:32 p.m., LPN #2 reported they missed the wounds when auditing new physician's orders and reported the wounds should have been care planned.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    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 record review and interview, the facility failed to ensure wound care assessments were accurate for a resident with wounds for one (#1) of three sampled residents whose wound documentation was reviewed. LPN #2 identified ten residents who had wounds. Findings: The Pressure Ulcer Treatment policy, undated, read in part, .Suspected Deep Tissue Injury: Purple or [NAME] localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed . Res #1 had diagnoses which included paraplegia, end stage renal disease, hepatitis c, diabetes and pressure ulcers. A wound care assessment, dated 05/22/24, documented Res #1 had a SDTI (Suspected Deep Tissue Injury) of the spinous process lower. A progress note, dated 05/22/24, documented in part, .Contacted doctor about wound care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to update the comprehensive person-centered care plans to reflect the residents' current needs for four (#2, 19, 30, and #46) of 15 sampled residents whose care plans were reviewed. The administrator identified 58 residents resided in the facility. Findings: A Care Planning-Interdisciplinary Team policy, read in part, .This facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . The resident, family members, and/or legal representative are encouraged to participate in the development of and revisions to the resident's care plan . 1) Resident #2's current physician's orders dated 07/31/23, documented may apply oxygen via nasal cannula at 2-4 LPM to keep oxygen saturations above 92%. Resident #2's quarterly assessment dated [DATE] documented the resident had no cognitive impairments and was not on oxygen therapy. On 04/15/24 at 12:15 p.m., an oxygen…

    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 · E2024-02-07 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure hot water was provided for the residents for approximately a month. The DON identified 58 residents resided in the facility. Findings: An invoice dated 01/09/24, documented two inch pipes were replaced with gas line thread tape to prevent gas leaks. An invoice dated 01/15/24, documented the valve ball fitting was replaced and pipes were replaced again. An invoice dated 01/16/24, documented a water heater connector and pipe had to be replaced. An invoice dated 01/19/24, documented the couple fitting, pipes, copper caps, an adapter, and a lower and upper thermostat were replaced. An invoice dated 01/23/24, documented a lower and upper thermostat was replaced with a water heating element. An invoice dated 01/26/24, documented parts were purchased again to repair the old water heaters. The plumber replaced the water heater pump and the gate valve. Once the pump and gate valve were repaired then the valve that was replaced blew off causing damage again. The pump was replaced with copper adapter, and ball…

    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 9 citations
  • Potential for harm · E2024-02-07 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to ensure residents received bathing as scheduled for four (#1, 2, 3, and #4) of four residents sampled for ADLs. The DON identified 58 residents who resided in the facility. Findings: 1. An annual assessment for Res #1, dated 12/26/23, documented the resident was severely cognitively impaired and required total assistance with ADLs. No recent bathing documentation was in medical record. 2. An annual assessment for Res #2, dated 11/01/23, documented the resident was cognitively intact and was independent with most ADLs. No recent bathing documentation was in medical record. On 02/01/24 at 11:43 a.m., Res #2 stated they refused to take a shower/bath many times related to the water being ice cold. On 02/07/24 at 11:49 a.m. an interview was conducted with a family member of Res #2. They stated the resident had not been given a shower/bath in almost four weeks. They also stated another family member had to take Res #2 to give them a shower and wash their hair. 3. A quarterly assessment for Res #3, dated 11/08/23,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-07 · 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 record review and interview, the facility failed to ensure all allegations of abuse were reported within two hours and a final report with five days for one (Res #1) of four residents sampled for abuse. The DON identified 58 residents residing in the facility. Findings: A facility policy, titled Abuse and Neglect - Clinical Protocol read in part, .15. The administrator will provide in a written report of the results of all abuse investigations and appropriate actions taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident . A statement by CNA #2, dated 08/06/23, documented while assisting CNA #1 with Res #1's shower, CNA #1 took the spray nozzle and ran it across the resident's hair and then stalled the nozzle on the resident's face for at least five seconds. The statement documented CNA #1 then pulled the sprayer off the resident's face and said [Res #1 name withheld] stop screaming, then when the resident resumed yelling,…

    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 · F2023-03-01 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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, observation, and interview, the facility failed to have an effective administration to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to: a. ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued NOMNC notices. b. ensure a significant change assessment was completed when residents experienced a change of status. c. update the comprehensive person centered care plan to reflect the residents' current needs. d. ensure the availability of staff present 24 hours a day who had current certification in CPR for Healthcare Providers, maintained their certifications, have a CPR policy, and ensure staff were familiar with facility policies related to CPR. e. ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; monitor and evaluate the effectiveness of the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-01 · 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

    3. Res #41 had diagnoses which included unspecified injury of left hip, Parkinson's disease, dementia, anxiety disorder due to known physiological condition, and pain. An annual MDS assessment, dated 10/25/22, documented the resident's cognition was severely impaired; was independent with most ADLs; had no impairment in ROM; used a walker and a wheelchair; and had one fall with no injury. The care plan, dated 11/02/21, documented the resident was at risk for falls. The interventions were documented as the following: a. Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. b. The resident needs prompt response to all requests for assistance. c. The resident needs a safe environment with floors free from spills and/or clutter; adequate, glare-free light; the bed in low position at night; side rails as ordered, handrails on walls, and personal items within reach. d. Ensure that the resident was wearing appropriate footwear, non-skid socks when ambulating or mobilizing in w/c. A facility incident report, dated 11/21/22 at 3:30 p.m.,…

    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 · E2023-03-01 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure physician ordered lab tests were obtained for one (#34) of five residents whose labatory orders were reviewed. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: Res #34 had diagnoses which included Alzheimer's disease, diabetes, and protein calorie malnutrition. A physician order, dated 12/31/21, documented the facility was to obtain a CBC, CMP, and lipid panel on readmission and every six months thereafter. A review of the residents clinical records was conducted and labs were drawn on 04/05/22 and as of 02/27/23 no labs were drawn according to physician orders after that time. A quarterly assessment, dated 01/23/23, documented the resident was severely impaired in cognitive skills for daily decision making and was mostly independent with ADLs. A care plan, last reviewed on 01/30/23, documented the facility was to obtain routine labs as ordered and notify the physician of the results. On 02/27/23 at 1:39 p.m., the ADON stated there should have been a…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-01 · tag F0888 — pattern
    Ensure staff are vaccinated for COVID-19
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to follow their COVID-19 staff vaccination policy and failed to ensure staff received all the vaccinations in the primary series, had an exemption, or were temporarily delayed in completing their vaccinations. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: The facility's COVID-19 Vaccine Policy, updated on 10/31/22, read in part: .Contingency plan for staff who are not fully vaccinated .A part of this contingency plan, a 30-day period, will be put in place starting first day of hire and/or first day of notice to staff member with staff member being informed that per Administration discretion, termination of employment may be enforced if steps have not been taken to complete vaccination series until staff member becomes in compliance . A review of the facilities current staff vaccination matrix documented 97% of the staff had completed the primary series of COVID - 19 vaccination, had an exemption, or was temporarily delayed in completing their vaccinations. 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 · Dcited before2023-03-01 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued NOMNC notices for two (#5 and #19) of three residents reviewed for beneficiary notices. The facility identified 21 residents who were discharged from part A skilled services with benefit days remaining in the previous six months. Findings: 1. Res #19 was admitted to part A skilled services on 09/09/22, discharged from skilled services on 11/17/22, and remained in the facility. Res #5 was admitted to part A skilled services on 11/30/22, discharged from skilled services on 01/13/23, and remained in the facility. On 02/24/23, the MDS coordinator was asked to provide ABN and NOMNC notifications for the sampled residents. On 02/24/23 at 2:18 p.m., the MDS coordinator provided an ABN notice and a form titled Determination on Continued Stay notice for Res #5 and #19. The Determination on Continued Stay notice was not the updated CMS form required to be provided. When asked for the NOMNC form CMS-10123,…

    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 · D2023-03-01 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure a significant change assessment was completed within 14 days after a resident experienced a change of status for two (#24 and #41) of 12 residents whose assessments were reviewed. The Resident Census and Conditions of Resident form documented 47 residents lived at the facility. Findings: 1. Res #24 had diagnoses which included ventricular tachycardia, congestive heart failure, and atrial fibrillation. A quarterly assessment, dated 12/03/22, documented the resident was moderately impaired in cognition, was independent with most ADLs, but did require limited assistance with dressing and hygiene. A nurse note, dated 02/03/23, documented the resident was admitted to hospice services. On 02/28/23 at 9:50 a.m., the resident was observed lying in bed and appeared to be asleep. An unidentified hospice aide was also in the room and reported she had just finished his cares. On 02/28/23 at 12:49 p.m., the MDS coordinator was interviewed regarding a significant change assessment. She stated the assessment was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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 physician provided an acceptable rational for not reducing a psychotropic medication and failed to monitor for side effects of the use of psychotropic medications for two (#24 and #34) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 22 residents received psychotropic medications. Findings: 1. Res #24 had diagnoses which included persistent mood disorder and anxiety disorder. A MRR, dated 04/09/22, documented a request for a reduction of Trazodone (an antidepressant medication) from 150 mg daily to 100 mg daily. The physician disagreed documented stable. Facility generated reduction requests, dated 09/01/22, documented Cymbalta (an antidepressant medication) 60 mg, Trazodone 150 mg at bedtime, quetiapine (an antipsychotic medication) 200 mg daily for reduction. The physician disagreed documenting stable. A MRR, dated 09/20/22, documented a request to reduce the dose 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.

    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.

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

$66,206 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $20,772 — penalty dated 2024-08-01
  • $45,434 — penalty dated 2024-02-07
  • Medicare payment denial — starting 2024-03-13 for 12 days

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

Who owns this facility

Owner / managerTypeRoleSince
MONTGOMERY, JAMES CIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2024
MONTGOMERY, BRADFORDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
WHITLEY, TINAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
FORVIS MAZARS LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/19/2025
HASKELL COUNTY NURSING CENTEROrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2008
INTERHEALTH, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/11/2025
ALDRICH, RYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
HIGHTOWER, RONALDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
STITES, GREGORYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024

CMS files one row per role, so the 23 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$4.3M
Net patient revenuemost recent cost report
+1.7%
Operating marginrevenue minus expenses
$89K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 6%Other / private 10%

About 84% 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 $89K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$209per resident / day
operating cost
$6,357per month
≈ monthly operating cost
$213per day
avg. revenue, all payers

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

What families pay in OK

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375497. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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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