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Sequoyah Pointe Skilled Nursing And Therapy

614 E Cherrie Street, Tahlequah, OK 74465 · For profit - Partnership · 125 certified beds · (918) 456-2573 Medicare & Medicaid certified

Call the home — (918) 456-2573 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Nov 2023
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
204 Woodlawn Ave · (918) 456-8000 · Call to confirm hours
Pharmacy
1301 E Downing St · (918) 456-2233 · Call to confirm hours
Grocery
Save A Lot<0.1 mi
614 E Downing St · (918) 456-6971 · Call to confirm hours
Park
Unnamed Road · 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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 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 3 to 4 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 rating4★
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 increased6.9%13.6%15.4%better
Long-stay residents who lose too much weight2.1%3.3%5.4%better
Long-stay residents with a catheter left in their bladder1.5%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.0%2.8%2.0%typical
Long-stay residents with depressive symptoms1.1%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 injury4.4%4.7%3.3%worse
Long-stay residents whose ability to walk worsened10.2%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.5%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine96.4%94.6%95.3%typical
Long-stay residents with pressure ulcers7.3%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control19.7%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table20.0%17.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.1%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine90.6%74.1%79.4%better
Short-stay residents rehospitalized after admission32.9%27.3%22.6%worse
Short-stay residents with an outpatient ER visit10.7%16.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.382.311.67worse
Long-stay outpatient ER visits per 1,000 resident days2.292.961.80worse

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.

62.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.7%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
37.5%U.S. median 56.6%
Met the expected recovery
0.13U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 37.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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 SNF62.7%CMS range 52.4–75.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 7.8–16.110.7%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 discharge37.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge20.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge25.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened13.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.1–12.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

0.26
RN hours/ resident / day
1.08
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.32
Total nurse hours/ resident / day
0.30
RN hoursweekends
49.0%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 125 beds and averages 58.1 residents a day — about 46% occupied, or roughly 67 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.00 hrs/resident/day on weekends vs 3.45 on weekdays — 13% thinner on weekends. RN hours go from 0.24 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2025-01-08)
7
at the previous standard inspection (2023-11-02)

Deficiencies are fewer than at the previous inspection — improving. 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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2025-05-15 · 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 05/13/25, a past noncompliance situation was determined to exist related to the facility's failure to provide supervision to protect residents. An incident report, dated 05/02/25, showed Resident #1 had left the facility without staff knowledge and was found by local police in a commercial establishment's parking lot approximately 400 feet from the facility. Resident #1 was returned to the facility within 30 minutes of their departure and was transferred to a secured facility two days later. Based on observation, record review, and interview the facility failed to ensure a resident with a history of elopement did not elope from the facility for 1 (#1) of 3 sampled residents reviewed for accident hazards. Corp. Nurse Consult. #1 reported five residents wandered at the facility. Findings: On 05/13/25 at 10:30 a.m., the lock on the kitchen door was observed during the initial tour. A facility document titled Elopement Risk Guideline, dated 04/2025, read in part, 1. The Elopement risk assessment is completed 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-01-08 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a call light was in reach for one (#35) of 24 sampled residents observed for call lights. The administrator identified 54 residents resided in the facility. Findings: Resident #35 had diagnoses which included chronic pain. The Care Plan, dated 09/28/22, documented to place call light within reach and to encourage the resident to use it. A Quarterly Assessment, dated 12/31/24, documented Resident #35's cognition was severely impaired. It documented the resident required assistance from staff for their ADLs and mobility. On 01/06/25 at 12:50 p.m., Resident #35 was observed laying in bed in their room. Resident #35 was heard screaming out wanting clean clothes. The call light was observed clipped to the privacy curtain out of reach of the resident. An orange sign was observed on the wall next to the resident's window. The sign read, Before leaving residents room please ensure all call light button are within residents reach. CNA #2 was observed going into Resident #35's room to provide care. On 01/06/25…

    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 · D2025-01-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan within 14 days of admission for one (#24) of 14 sampled residents whose care plans were reviewed. The DON identified 54 residents resided at the facility. Findings: Resident #24 was admitted to the facility on [DATE] with diagnoses which included acute kidney failure, acute cystitis with hematuria, and indwelling urinary catheter. On 01/06/25 at 2:22 p.m., no comprehensive care plan was present in the EHR nor paper chart for Resident #24. On 01/08/25 at 8:21 a.m., the ADON was asked the process for completing comprehensive care plans for new admissions. They stated care plans for residents receiving skilled services were completed by the corporate nurse within 14 days of admission. After a review of Resident #24's care plan, the ADON acknowledged it had not been completed within 14 days of admission.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-08 · 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

    Based on observation, record review and interview, the facility failed to ensure heel lift boots were in place as ordered for one (#36) of two sampled residents reviewed for pressure ulcer care. The administrator identified seven residents had orders for heel lift boots. Findings: Resident #36 had diagnoses which included left side hemiplegia. Resident #36's Order Summary Report, dated 05/03/23, documented for heel lift boots to be in place every shift for wound prevention. A Braden Scale for Predicting Pressure Sore Risk assessment, dated 12/18/24, documented Resident #36 was at high risk for developing a pressure ulcer A Quarterly Assessment, dated 12/18/24, documented Resident #36's cognition was severely impaired. It documented the resident had impairment to their upper and lower extremities. On 01/06/25 at 2:31 p.m., Resident #36 was observed laying in their bed. Heel lift boots were not observed on the resident's feet. On 01/07/25 at 7:45 a.m., Resident #36 was observed up in their geri chair in their room. Heel lift boots were not observed on the resident's feet. On 01/07/25…

    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 · Fcited before2023-11-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The administrator reported 58 residents resided in the facility. Findings: On 10/26/23 at 10:20 a.m., a tour of the kitchen was conducted. The following observations were made: a. The handwashing sink was observed to have a brown dirt like substance on the back of it. b. A sink and countertop in the dry storage area was observed to have a red sticky substance on it. c. The cabinet under the sink in the dry storage was observed to be open exposing the pipes. d. A freezer temperature was observed to be at 38 degree Fahrenheit. The freezer contained a box of corn dogs, a bag of garlic bread, and a box of tater tots. All the foods were observed not frozen. The temperature log documentation stopped on 10/04/23. e. The stove/oven was observed to have a grease film on the front and down the sides. A dried white substance was observed on the oven door and the side of the oven. f. A three compartment sink in the cooking area was observed to have a bucket under…

    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 · E2023-11-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure the facility maintained a clean, odor-free, and homelike environment. The CMS 671 form, dated 10/26/23, documented 58 residents resided in the facility. Findings: A Housekeeping Policies and Procedures packet, revised 06/29/12, read in parts, .Every resident room should undergo complete wet cleaning, disinfection and deodorizing daily .Pick up all litter on resident room floor and bathroom floor .Dust mop, making sure closet and areas under furniture are included . On 10/26/23 at 1:00 p.m., the following observations were made: a. The east hallway had a strong smell of urine, b. room [ROOM NUMBER] had a strong smell of urine. A bedside commode was observed located beside the bed with a large amount of medium yellow urine observed inside the basin. The bottom of the commode basin had dark yellow and brown stains. c. room [ROOM NUMBER] had large amount of dust and food debris observed underneath and around both beds. Multiple dead cockroaches…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-02 · 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 were bathed as scheduled for two (#8 and #43) of five sampled residents reviewed for bathing. The CMS 671 form, dated 10/26/23, documented 58 residents resided in the facility. Findings: 1. Res #43 was admitted with diagnoses which included respiratory failure, depressive disorders, and anxiety. An admission assessment, dated 06/07/23, documented the resident was cognitively intact and required extensive one person physical assistance with bathing. A care plan, dated 06/16/23, documented the resident was to be bathed with the physical help of one person every Monday, Wednesday, and Friday during the 7 a.m. to 3 p.m. shift. The August 2023 bathing record documented Res #43 was bathed four out of 13 opportunities. The September 2023 bathing record documented Res #43 was bathed six out of 13 opportunities. The October 2023 bathing record documented Res #43 was bathed four out of 13 opportunities. On 10/26/23 at 2:12 p.m., Res #43 stated they were upset because they often have not received their…

    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 · E2023-11-02 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to document and retain daily staffing information for the past 18 months. The CMS 671 form, dated 10/26/23, documented a census of 58 residents. Findings: On 10/26/23 at 11:00 a.m. and throughout the survey, the white boards behind each nursing station was observed to include documentation of the census number, name and titles of the staff on duty. Staffing hours were not documented. On 11/02/23 at 11:55 a.m., the administrator reported they were not aware of the requirements to post staffing hours and retain the documentation for 18 months.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-02 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a resident who was physically restrained was assessed, monitored, and the restraint was used to treat a medical symptom for one (#16) of one sampled resident who was reviewed for seat belt usage. The DON identified one resident who used a seat belt. Findings: Res #16 was admitted with diagnoses which included Alzheimer's, dementia with behavioral disturbances, muscle weakness, neuropathy, macular degeneration and age-related osteoporosis. A fall risk care plan initiated on 03/21/18, documented Res #16 was at risk for falls due to requiring staff assistance with ADL's and psychotropic medication use. A non-restraint safety devices care plan initiated on 03/21/18, documented Res #16 may use an alarming self-releasing seatbelt when up in wheelchair. The care plan also documented Res #16 was able to release belt at will and upon request. A list of falls from 06/10/22 to present was provided by the DON and documented Res #16 had 11 falls. A physician order dated, 01/15/23, read in part, May use alarming…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#8) of one sampled residents reviewed for PASRR. The administrator reported 37 residents had mental health diagnoses. Findings: Res #8 was admitted to the facility on [DATE] with diagnoses of intellectual disabilities and mood disorder due to known physiological condition. A PASRR level I, dated 02/12/13, documented Level II cleared, eligible for admission to LTC 02/06/13. The resident record documented the resident received a new diagnosis of schizophrenia on 08/19/22. The record contained no documentation that OHCA was contacted about the new diagnosis. On 11/02/23 at 8:36 a.m., MDS #1 reported that OHCA should have been contacted about the new mental health diagnosis.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2023-11-02 · 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 — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to update a comprehensive care plan for one (#20) of one sampled resident who was reviewed for a PEG tube. The DON reported there was one resident with a PEG tube. Findings: Res #20 was admitted with diagnoses which included dementia and anorexia. Res #20's tube feeding care plan, dated 08/25/23, documented an enteral feed order of Jevity 1.5 cal 45 ml every hour. A physician order, dated 09/04/23, documented enteral feed order of Jevity 1.5 cal 273 four times a day. On 11/02/23 at 11:55 a.m., the DON reported the care plan should have been updated because Res #20 no longer received continuous feedings.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-01 · tag F0641 — pattern
    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 accurately assess for the presence of a PASRR level II for three (#3, 35 and #49) of 16 residents whose assessments were reviewed. The ''Resident Census and Conditions of Residents'' form documented 51 residents lived in the facility. Findings: 1. Res #3 had diagnoses which included generalized anxiety disorder, impulse disorder, major depressive disorder recurrent, and paranoid schizophrenia. A PASRR level II assessment, dated 11/30/17, documented Res #3 had been found to have a serious mental illness as defined by CMS during the Pre-admission Screening and Resident Review. An annual comprehensive resident assessment, dated 12/26/21, documented Res #3 was not considered by the state level II PASRR level II process to have a serious mental illness. 05/26/22 at 1:40 p.m., the MDS coordinator reviewed Res #3's comprehensive assessment and reported the assessment did not document the resident was identified as requiring a PASRR level II. The MDS coordinator stated the PASRR level II should have been documented in 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 · Ecited before2022-06-01 · tag F0644 — pattern
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure a resident newly diagnosed with a serious mental illness was referred for a PASRR level II evaluation and failed to incorporate PASRR level II recommendations into a resident care plan for three (#3, 48, and #29) of three residents reviewed for PASRR. The administrator reported 14 residents with PASRR Level II evaluations lived in the facility. Findings: 1. Res #3 had diagnoses which included generalized anxiety disorder, impulse disorder, major depressive disorder recurrent, and paranoid schizophrenia. A PASRR level II assessment, dated 11/30/17, documented Res #3 had been found to have a serious mental illness as defined by CMS during the Pre-admission Screening and Resident Review. The PASSAR Level II document read in parts: .Self - Monitoring of Health Services. Requires total assistance with monitoring health status due to being unaware of personal health and health risk . Self - Monitoring and scheduling of treatment Requires total assistance with monitoring and scheduling of treatments due 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-01 · 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 record review, observation, and interview, the facility failed to ensure dependent residents were provided assistance with bathing/showers, grooming, and incontinent care for four (#35, 38, 103, and #104) of five sampled residents reviewed for staff assistance with ADLs. The Resident Census and Conditions of Residents report documented 21 residents required assistance with bathing and 25 residents are occasionally or frequently incontinent of bladder. Findings: 1. Res #35 admitted to the facility and had diagnoses which included morbid obesity. A physician order, dated 01/14/22, documented the resident was to receive a bath one time a day on the 7 a.m. to 3 p.m. shift Monday, Wednesday, and Friday. A quarterly assessment, dated 04/10/22, documented the resident was intact with cognition and required limited assistance with personal hygiene, extensive assistance with toilet use, total assistance with bathing, and was always incontinent of bowel and bladder. A care plan, last review date 04/28/22, documented the resident was incontinent and to check every two hours and as…

    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 · E2022-06-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 provide services to prevent urinary tract infections for two (#37 and #102) of two residents reviewed for indwelling urinary catheters. The Resident Census and Conditions of Residents report documented two residents who required indwelling urinary catheters. Findings: 1. Res #102 had diagnoses which included neuromuscular dysfunction of the bladder and urinary tract infections. A physician order, dated 02/20/21, documented to clean the resident's indwelling suprapubic catheter every shift and PRN. A nurse note, dated 03/01/21, documented the resident continues IV meropenum (an antibiotic) for a UTI. A quarterly assessment, dated 03/20/21, documented the resident was severely impaired with cognition, required total assistance with activities of daily living, and had an indwelling urinary catheter. ADL flow sheets for March 2021 documented the staff did not record urinary output for 15 shifts from 03/01/21 through 03/19/21. The TAR for March 2021 documented for six shifts the resident catheter was not cleaned. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-01 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Resident #37 had diagnoses including neuromuscular dysfunction of bladder, and urinary tract infection. A physician order dated, 10/28/21, documented to perform catheter care every shift and as needed with soap and water or disposable wipes. A review of the treatment administration record did not document catheter care had been performed on 04/02/22, 04/03/22, 04/07/22, 04/09/22, 04/18/22, 05/13/22, and 05/21/22. A physician order, dated 10/28/2021, documented to change suprapubic catheter drainage bag on the 1st and 15th and as needed. A review of the treatment administration record documented the suprapubic catheter drainage bags had not been changed on 04/01/2022, and 05/15/2022. A physician order, dated 03/02/22, documented to collect vital signs every shift. A review of records for April and May of 2022 did not document vital signs were not completed for one or more shifts on the following dates: 04/01/22, 4/02/22, 04/03/22, 04/06/22, 04/07/22, 04/09/22, 04/18/22, 04/24/22, 04/29/22, 04/30/22, 05/02/22,…

    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 · E2022-06-01 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure nurse aids who had been employed greater than one year completed a performance review. The administrator reported the facility employed four CNAs who had worked at the facility for greater than one year. Findings: On 05/31/22 at 5:00 p.m., the administrator was asked to provide documentation of nurse aide competencies for any CNAs who had worked greater than one year at the facility. On 05/31/22 at 5:20 p.m., the DON and administrator reported the last skills performance reviews for CNAs had last been conducted in 2019. The administrator stated because of the pandemic and staffing issues the skill performance reviews had been overlooked.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-01 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed provide pharmaceutical services including dispensing per physician order and failed to ensure an accurate accounting of controlled drugs for four, (#3, 33, 37, and #50) of five residents reviewed for unnecessary medication. The Resident Census and Conditions of Residents form documented 51 residents who resided in the facility. Findings: 1. Res #3 had diagnoses which included diabetes, anxiety disorder, paranoid schizophrenia, and major depressive disorder. A quarterly resident assessment, dated 05/11/22, documented Res #3 received insulin, antipsychotic, antianxiety, antibiotics, and opioid medications during the assessment period. A medication administration record, printed on 05/26/22, did not documented the facility administered Res #3's medications as ordered on 05/01/22, 05/07/22, 05/08/22, and 05/14/22. A care plan for Res #3, reviewed on 05/18/22, documented the facility was to administer the resident's medications as ordered. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-01 · 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, observation, and interview, the facility failed to obtain physician ordered PT/INR labs for one (#48) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 51 residents resided in the facility. Findings: Resident #48 had diagnoses that included coagulation deficits, hemiplegia following cerebral infarction, and cerebrovascular disease. A physician order, dated 3/25/22, documented the facility was to administer Coumadin 4 mg tablet one time a day for a diagnosis of hemiplegia and hemiparesis following a cerebral infarction. A physician order dated 03/25/22 documented to collect a PT/INR in one week, two weeks, and then monthly. There were no lab results for the one week (04/01/22), and two week (04/15/22) draws. An annual assessment, dated 05/01/22, documented Res #48 received an anticoagulant for five days of the assessment period. A review of Res #48's clinical records did not contain PT/INR lab results for 04/01/22 or 04/15/22. On 05/25/22 at 5:09 p.m., the missing labs were requested from…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 food was stored, prepared, and served in a sanitary manner. The Census and Conditions of Residents form documented 51 residents lived in the facility. Findings: On 05/24/22 at 11:24 a.m., the refrigerator on the right side of the kitchen was observed and a staff member's purple insulated reusable lunch container was observed on the middle shelf next to a box containing heads of leaf lettuce. On 05/26/22 at 7:49 a.m., an observation was made of a staff's 32 oz metal cup (navy blue) in color with a straw and a black messenger style bag with white trim next to it on the top left side of the dish drying rack. On 05/26/22 at 8:08 a.m., DM stated that the staff's personal items must be kept in a designated area, usually her office, away from food and clean dishes. She stated the cups must be covered and have a straw. She stated the purses/bags should be hung up and there should not be staff personal items on the dish drying rack.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-01 · tag F0880 — failed to prevent and control infections — pattern
    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 record review, observation, and interview, the facility failed to implement CDC guidelines for infection control procedures to prevent the transmission of COVID-19 and/or other infections for the residents who resided in the facility. The facility failed to administer medications in a sanitary manner, properly use hand hygiene when assisting residents with eating, and not eat in the medication rooms of the facility. The Resident Census and Conditions of Residents report documented 51 residents lived in the facility. Findings: 1. On 05/26/22 at 8:30 a.m., an observation was made of CMA #1 dropping a resident's medication on the medication cart, The CMA was observed to pick up the the dropped medication with bare hand, placed in a medication cup with other medication, and administered it to the resident. On 05/26/22 at 1:29 p.m., CMA #1 stated she just picked the pill up and put it in the cup because medication was expensive. She was asked what should she have done with the medication. She stated she should have destroyed it. On 05/31/22 at 4:23 p.m., the DON stated the CMA…

    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 · D2022-06-01 · tag F0756 — failed to review each resident's drug regimen — isolated
    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 attending physician responded to medication regimen reviews for one (#33) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 51 residents resided in the facility. Findings: Res #33 had diagnoses which included Alzheimer's disease, dementia with behavioral disturbances, and major depressive disorder. A physician order, dated 09/16/21, documented Trazodone (an anti-depressant) 50 mg, half tablet to be administered as needed every six hours for anxiety. A pharmacy MRR, dated 09/23/21, documented the pharmacist requested a stop date for the as needed Trazodone order, since it had only been used two times since the medication was added. A pharmacy MRR, dated 11/30/21, documented the as needed order for Trazodone was used one time in the last 60 days, and a stop date was requested by the pharmacist. Pharmacy medication regimen reviews dated 12/17/21, 01/18/22, 02/16/22, 03/14/22, and 04/12/22 documented a stop date for the as needed Trazodone 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.

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to BRIDGES HEALTH — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.6+0.4 vs chain
Health inspection 4 of 53.5+0.5 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 2 of 53.0-1.0 vs chain
The other 32 homes this chain runs (chain average 3.6★, per CMS)
1 of 5Brookwood Skilled Nursing and TherapyOklahoma City, OK 1 of 5The Timbers Skilled Nursing and TherapyEdmond, OK 2 of 5Ambassador Manor Nursing CenterTulsa, OK 2 of 5Fairmont Skilled Nursing and TherapyOklahoma City, OK 2 of 5Grace Skilled Nursing and Therapy JenksJenks, OK 2 of 5Stillwater Creek Skilled Nursing And TherapyStillwater, OK 2 of 5The Grand At Bethany Skilled Nursing And TherapyBethany, OK 3 of 5Capitol Hill Skilled Nursing And TherapyOklahoma City, OK 3 of 5Claremore Skilled Nursing and TherapyClaremore, OK 3 of 5Glenwood Skilled Nursing And TherapyGlenpool, OK 3 of 5The Springs Skilled Nursing And TherapyMuskogee, OK 3 of 5The Wilshire Skilled Nursing And TherapyOklahoma City, OK 3 of 5Wildewood Skilled Nursing And TherapyOklahoma City, OK 4 of 5Bradford Village Healthcare CenterEdmond, OK 4 of 5Cottonwood Creek Skilled Nursing & TherapyChickasha, OK 4 of 5English Village Skilled Nursing And TherapyAltus, OK 4 of 5Heritage Skilled Nursing And TherapyTecumseh, OK 4 of 5Kingwood Skilled Nursing and TherapyOklahoma City, OK 4 of 5Magnolia Creek Skilled Nursing And TherapyAltus, OK 4 of 5Mid-Del Skilled Nursing And TherapyDel City, OK 4 of 5St. Ann's Skilled Nursing And TherapyOklahoma City, OK 4 of 5The CommonsEnid, OK 4 of 5University Park Skilled Nursing And Therapy MemoryTahlequah, OK 4 of 5Woodward Skilled Nursing And TherapyWoodward, OK 5 of 5Grace Skilled And Nursing Therapy NormanNorman, OK 5 of 5Holiday Heights HealthcareNorman, OK 5 of 5Mangum Skilled Nursing And TherapyMangum, OK 5 of 5River Oaks Skilled Nursing And TherapyEl Reno, OK 5 of 5River Valley Skilled Nursing And TherapyClinton, OK 5 of 5Senior Village HealthcareBlanchard, OK 5 of 5The Regency Skilled Nursing And TherapyShawnee, OK 5 of 5Western Skilled Nursing And TherapyBuffalo, OK

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BRIDGES EMPLOYEE STOCK OWNERSHIP TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 12/31/2020
DEROIN, KRISTYIndividualW-2 MANAGING EMPLOYEEsince 01/01/2019
COBLE, WILLIAMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/31/2020
BRIDGES ESOP, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/31/2020

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$5.9M
Net patient revenuemost recent cost report
+0.0%
Operating marginrevenue minus expenses
$531K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 9%Other / private 13%

About 77% 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 $531K 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

$273per resident / day
operating cost
$8,305per month
≈ monthly operating cost
$273per 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 375124. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-08, 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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