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University Park Skilled Nursing And Therapy Memory

1201 North Vinita Avenue, Tahlequah, OK 74464 · For profit - Partnership · 139 certified beds · (918) 456-6181 Medicare & Medicaid certified

Call the home — (918) 456-6181 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Oct 2022
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — 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 (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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) 4 of 5
Quality measuresSelf-reported by the facility 3 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
614 E Downing St · (918) 456-6971 · Call to confirm hours
Park
400 N Muskogee Ave · (918) 456-3742 · 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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased7.3%13.6%15.4%better
Long-stay residents who lose too much weight2.6%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%2.8%2.0%better
Long-stay residents with depressive symptoms0.0%3.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.9%4.7%3.3%worse
Long-stay residents whose ability to walk worsened9.7%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication41.8%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.1%94.6%95.3%typical
Long-stay residents with pressure ulcers2.8%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control14.6%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.6%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine81.0%74.1%79.4%typical
Short-stay residents rehospitalized after admission26.8%27.3%22.6%worse
Short-stay residents with an outpatient ER visit22.7%16.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.522.311.67worse
Long-stay outpatient ER visits per 1,000 resident days2.432.961.80worse

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

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

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

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

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

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

0.07U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.07 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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 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 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 stay7.4%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 worsened7.4%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 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 SNFs0.981.02Oct 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

0.32
RN hours/ resident / day
1.04
LPN hours/ resident / day
2.57
Aide hours/ resident / day
3.93
Total nurse hours/ resident / day
0.19
RN hoursweekends
34.7%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 139 beds and averages 47.9 residents a day — about 34% occupied, or roughly 91 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 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.95 hrs/resident/day on weekends vs 3.92 on weekdays — about the same on weekends as weekdays. RN hours go from 0.37 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%. 1 administrator has left in the past year.

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 (2025-03-10)
5
at the previous standard inspection (2023-11-30)

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

Inspection deficiencies

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

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · E2025-03-10 · 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 that annual competency reviews were completed for 2 (CNA #2 and CNA #3) of 5 staff members reviewed for annual competency reviews. The administrator identified 49 residents resided in the facility. Findings: 1. CNA #3 was hired on 04/10/03. 2. CNA #2 was hired on 04/11/22. CNA #3 and CNA #2's personnel files were reviewed and did not contain annual competency reviews. On 03/06/25 at 2:37 p.m., the administrator was asked to provide documentation of the annual competency reviews for CNA #3 and CNA #2. On 03/10/25 at 1:20 p.m., the administrator stated they were unable to locate the annual competency reviews for CNA #3 and CNA #2.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to perform post fall neurological checks for 1 (#49) of 1 death record reviewed. The administrator identified 49 residents resided in the facility. Findings: The Fall Program policy, revised 05/24, read in part, Complete incident report and include neurological check sheet if suspect or confirmed the resident hit their head. Resident #49 had diagnoses which included epilepsy, history of falling, and unspecified sequelae of cerebral infarction. An Incident Report, dated 01/12/25, read in part, Unwitnessed fall. Resident was found by staff on the floor in prone position in front of his wheelchair in the lobby. Full head to toe assessment completed at the time of incident. Laceration to forehead with moderate bleeding noted. Laceration to right hand with moderate bleeding noted. Pressure dressing applied to both sites and EMS contacted. EMS left with resident at approximately 2000 [8:00 p.m.] Notified DON, administrator and son of transfer. A hospital…

    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 · D2025-03-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 oxygen concentrator filters were sanitary for 1 (#39) of 2 sampled residents reviewed for respiratory care. The administrator identified seven residents received oxygen in the facility. Findings: On 03/04/25 at 2:12 p.m., Resident #39's oxygen concentrator filters were observed to have moderate dust build up. The Cleaning Oxygen Concentrators policy, revised 02/27/20, read in part, Oxygen concentrators are cleaned monthly or every four weeks, and as needed. Resident #39 had diagnoses which included shortness of breath and sleep apnea. On 03/06/25 at 2:08 p.m., LPN #2 stated the filters were dirty and had dust build up. They stated they needed to be cleaned. On 03/06/25 at 2:10 p.m., the DON stated the oxygen concentrator filters were to be cleaned monthly. They stated they put an order in the system for the cleaning to keep track but no order was needed. On 03/06/25 at 2:14 p.m., LPN #2 reviewed Resident #39's orders. They stated there was no order to clean the oxygen concentrator filters. On 03/06/25…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-10 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 post dialysis documentation had been completed for 1 (#26) of 1 sampled resident reviewed for dialysis. The facility MDS [minimum data set] Resident Matrix, showed one resident received dialysis. Findings: Resident #26 had diagnoses which included end stage renal disease. The Dialysis Communication forms, read in part, B. Post Dialysis This section to be completed by dialysis unit and returned with the resident: A. Blood pressure B. Pulse C. Respirations D. Temperature E. Pre dialysis weight E1. Post dialysis weight F. Time dialysis started G. Time dialysis ended H. Check all that apply 1. dressing dry and intact 2. ports capped and clamped 3. pain 4. bleeding 5. new orders sent with resident 6. s/s of infection. A physician's order, dated 08/22/22, showed the resident was to receive dialysis weekly Tuesday, Thursday, and Saturday. A quarterly resident assessment, dated 02/20/25, showed the resident was cognitively intact and received dialysis while in the facility. The Dialysis Communication forms dated, 02/19/25,…

    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 · D2025-03-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for 1 (#30) of 1 sampled resident reviewed for urinary catheters. The DON reported five residents with urinary catheters. Findings: On 03/07/25 at 8:19 a.m., LPN #1 and the ADON were observed providing catheter care for Resident #30, they were not observed to be wearing gowns. An Infection Control and Isolation Policy, revised 03/28/24, read in part, EBP are indicated for residents with any of the following .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO.EBP expands the use of PPE [personal protective equipment] and refer to the use of gown and gloves during high-contact resident care activities. Resident #30 had diagnoses which included benign prostate hyperplasia and diabetes mellitus. A physician's order, dated 10/31/24, showed catheter care was to be completed every shift and as needed. A physician's order, revised 11/01/24, showed enhanced barrier precautions were to be used because…

    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 · D2025-01-27 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    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 the regulatory requirements for transfer and discharge a resident for one (#1) of one sampled resident reviewed for discharge. The charge nurse reported the census was 49. Findings: Resident #1 had diagnoses which included dementia and psychotic disorder. A nurse's note, dated 01/01/25 at 8:30 p.m., documented LPN #1 notified RN #1 that Resident #1 was threatening to leave the facility and stating they could not force them to stay in the facility. The note also documented the on call physician was contacted and they requested a BIMS assessment (an assessment to determine cognitive statue) be completed. The note documented the assessment was completed and the resident was cognitively intact. The note documented if the resident insisted on discharging the discharge would be AMA. A police report #2501T0167, dated 01/01/25, documented a police officer observed Resident #1 standing on the side of the road. The report stated the police officer contacted Resident #1 and they reported they had been kicked out of the motel.…

    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 before2025-01-27 · 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

    Based on record review and interview, the facility failed to provide supervision to prevent elopement for one (#1) of three sampled residents reviewed for elopement. The charge nurse reported the census was 49. Findings: Resident #1 had diagnoses which included dementia and psychotic disorder. A care plan, initiated 12/12/24, documented Resident #1 was at risk for leaving the facility related to confusion and they needed staff to monitor their location. A Medicare five-day assessment, dated 12/13/24, documented Resident #1 was severely impaired for daily decision making. A nurse's note, dated 12/16/24 at 12:40 a.m., documented Resident #1 was going into other resident rooms and required redirection. A nurse's note, dated 12/16/24 at 1:25 a.m., documented Resident #1 had blocked the entrance to their room and Resident #1 had opened their window more than once during this shift. A nurse's note, dated 12/16/24 at 4:43 a.m., documented Resident #1 had been going into other resident rooms. A nurse's note, dated 12/19/24 at 2:49 p.m., documented Resident #1 had been wandering and exit…

    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 · D2025-01-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure medical records were complete and accurate for one (#1) of three sampled residents reviewed for elopement. The charge nurse reported the facility census was 49. Findings: A facility policy titled Content of Resident Medical Records, revised on 08/19/03, read in part, A medical record is to be completed as a confidential medicolegal document containing sufficient data to identify the resident, justify the diagnosis and treatment, and document the end results accurately. Resident #1 had diagnoses which included dementia and psychotic disorder. A nurse's note, dated 01/01/25 at 8:30 p.m., documented LPN #1 notified RN #1 that Resident #1 was threatening to leave the facility and stating that they could not force them to stay in the facility. The note also documented that the on call physician was contacted and they requested a BIMS assessment (an assessment to determine cognitive statue) be completed. The note documented the assessment was completed and the resident was cognitively intact. The note documented that if…

    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 · Fcited before2023-11-30 · 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, record review, and interview, the facility failed to ensure food and dishes were stored properly. The administrator identified all residents received services from the kitchen. Findings: A Food Storage policy, dated 04/20/09, read in part, .Storage: Area .floor should be .regularly cleaned .Shelving should be .cleaned .Any opened products should be placed in zip lock bags . On 11/27/23 at 12:28 p.m., a tour of the kitchen was conducted. The following observations were made: a. a blue bag of shredded cheese and a gallon bag of sliced cheese were not sealed or dated in the walk in refrigerator, b. several beans were observed on bottom shelf in dry storage not in a container/bag, c. a container of all purpose mix with the lid not secured in the dry storage, d. one potato on the floor under empty crates in the dry storage area, and e. different sized bowls and plates on multiple shelves next to dishwasher area were faced up and not inverted. On 11/28/23 at 10:00 a.m., a follow up tour of the kitchen was conducted. The following observations were made: a. several…

    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 · E2023-11-30 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 activities were provided for two (#52 and #53) of 24 sampled residents reviewed for activities. The administrator identified 52 residents resided in the facility. Findings: An Activities Policy, dated 03/07/01, read in part .It is the policy of this facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each elder . 1. Resident #52 had diagnoses which included, dementia, Alzheimer's disease, anemia, and depressive disorder. Resident #52's admission assessment, dated 06/22/23, documented Resident #52's activity preferences as very important to have books and magazines to read, listen to music, be around animals, keep up with the news, do their favorite activities, go outside when the weather was good, and participate in religious services or practices. On 11/28/23 at 10:17 a.m., Resident #52 was observed sitting in their room watching television and was asked if they…

    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
Show the remaining 18 citations
  • Potential for harm · E2023-11-30 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure two treatment carts were locked. The administrator identified seven medication/treatments carts were utilized in the facility. Findings: A Storage of Medication policy, dated January 2022, read in part, .Medication .carts .are locked when not attended by persons with authorized access . On 11/27/23 at 1:09 p.m., a treatment cart was observed to be unlocked on hall 100. No staff were observed around the unlocked treatment cart. On 11/27/23 at 1:11 p.m., LPN #1 was observed to notice the cart was unlocked and went to lock the treatment cart. They were asked what the policy was for securing a treatment cart. They stated staff were not to leave it unlocked. On 11/29/23 at 7:18 a.m., LPN #2 was observed to prep an insulin pen for administration. They were observed to go in to the resident's room, close the door, and had left the treatment cart unlocked on hall 200. On 11/29/23 at 7:20 a.m., two other surveyors observed the treatment cart unlocked. On 11/29/23 at 7:22 a.m., LPN #2 was asked how staff secured…

    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 · Dcited before2023-11-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 maintain a clean, homelike environment for one (#29) of 24 sampled residents reviewed for a homelike environment. The administrator identified 52 residents resided in the facility. Findings: A Housekeeping policy, revised 06/29/12, read in part .Every resident room should undergo complete wet cleaning, disinfection, and deodorizing daily . Resident #29 had diagnoses which included dementia and psychotic disorder. A quarterly assessment, dated 10/12/23, documented Resident #29 had moderate cognitive impairment, and was frequently incontinent of bowel and bladder. On 11/28/23 at 9:50 a.m., Resident #29 was observed in their room sitting in their recliner. A bag of trash was on the floor near the recliner, a towel was observed between the recliner and the wall on the floor. The floor was sticky when walking on it and an old urine odor was noted in the room. On 11/29/23 at 9:19 a.m., an observation was made in Resident #29's room. The resident stated, they had seen bugs and was asked when was the last time they…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure range of motion exercises were completed for one (#39) of one sampled resident reviewed for range of motion. The administrator identified 52 residents resided in the facility. Findings: A Range of Motion policy, dated 10/01/01, read in part .active or passive, range of motion is done to reduce muscle wasting, weakening, and prevents or reduces the development of contractures . Resident #39 had diagnosis which included hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage, gait abnormalities, and unsteadiness on feet. A quarterly assessment, dated 09/21/23, documented a BIMS score of 13, extensive assistance with bed mobility, transfer, and toilet use with one staff assistance and limited assistance with dressing. Resident #39's care plan, dated 09/27/23, read in part, .resident experienced cerebral vascular accident .range of motion exercises several times a day. If resident is able, teach how to do correct active range of motion . 11/29/23 at 9:53 a.m., Resident #39 was asked if they were…

    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 · E2022-10-11 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment was ensured for two (#35 and #52) of four residents reviewed for advanced directives. The facility failed to offer information on advanced directives to Res #35 and failed to ensure the individual who had the authority to sign for resident #52 signed the resident's DNR form. The Resident Census and Conditions of Residents form documented 17 residents with advanced directives resided in the facility. Findings: 1. Res #35 had diagnoses which included dementia, cerebral infarction, chronic respiratory failure, and paranoid schizophrenia. A physician order, dated 07/18/22, documented Res #35 was to be resuscitated in the event of cardio-pulmonary arrest. An annual MDS assessment, dated 08/25/22, documented Res #35 had a serious mental illness, was intact in cognition, and was independent to requiring supervision with most ADLs. On 10/05/22 at 4:36 p.m., Res #35's door was observed and documented their name on a green name tag indicating…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-11 · 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 a safe, clean, comfortable, and homelike environment for residents, visitors, and staff. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: 1. On 10/05/22 at 3:42 p.m., Res #9 stated the grab bar in the shower on hall 100 was very loose and felt it was an accident waiting to happen. On 10/05/22 at 3:56 p.m., the shower room on hall 100 was observed. The grab bar in the shower was very loose and pulled away from the wall. There was a black substance observed on the ceiling in the shower. On 10/10/22 at 3:43 p.m., the grab bar in the shower room on the 100 hall was observed to be loose and pulled away from the wall approximately an inch. On 10/10/22 at 3:44 p.m., a hospice CNA brought Res #62 into the shower room for his shower. Res #62 was asked if he used the grab bar in the shower. Res #62 stated it would be helpful if he could use the grab bar to stand. On 10/10/22 at approximately 4:50 p.m., CNA #2 was asked about the grab bar 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-11 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessments accurately reflected the residents' status for two (#4 and #35) of five residents sampled for medication review. The Resident Census and Conditions of Residents form documented 22 residents on antipsychotic medications. Findings: 1. Res #4 was admitted on [DATE] and had diagnoses which included dementia with other behavioral disturbance, major depressive disorder recurrent severe, impulse disorder, anxiety disorder, delusional disorder, insomnia, psychosis not due to a substance or known physiological condition. A physician order, dated 04/20/18 and discontinued on 11/02/18, documented Risperdal (an antipsychotic medication) 0.5 mg at bedtime related to impulse disorder. An annual MDS assessment, dated 07/07/22, documented the resident was cognitively intact, had minimal depression, no behaviors, and received antipsychotic and antidepressant medication. The assessment documented a GDR had not been attempted. On 10/07/22 at 10:08…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide routine weekly pressure ulcer assessments, failed to provide physician ordered treatments, failed to notify the physician and obtain orders, and failed to perform appropiate hand hygiene during wound care for four (#20, 52, 54, and #56) of four residents sampled for pressure ulcers. The Resident Census and Conditions of Residents form documented three residents with pressure ulcers. Findings: An undated facility policy, titled Pressure Ulcer Policy, read in part, .within eight hours of initial admission or following hospital stay the resident will be assessed for the existence of pressure ulcers. The attending physician will be notified to obtain treatment interventions. Also, the wound care nurse(s) and charge nurse should be notified . 1. Res #20's admission MDS assessment, dated 11/14/21, documented the resident was independent with ADLs and had one pressure ulcer on admission and one surgical wound. A physician order, dated…

    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 before2022-10-11 · 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

    Based on observation, record review,and interview, the facility failed to identify and implement interventions to prevent falls for two (#36 and #54) of four residents reviewed for falls. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: A facility policy, titled Fall Awareness Program, revised 11-27-17, read in part, .Fall Occurs: 1. Assess the resident for injuries, .Complete incident report .2. Complete additional fall risk assessment tool .4. develop care plan using appropriate interventions .9. Review and revise the care plan as needed .11. Review the fall at the next Safety committee meeting and gain input for interdisciplinary team members for other possible interventions to prevent falls. Make sure to update and revise plan of care as indicated . 1. Res #36 had diagnoses which included Alzheimer's disease, bipolar disease, and polyneuropathy. An incident note, dated 05/15/22, documented Res #36 had experienced an unwitnessed fall in her room and was found on the floor beside her bed. The note documented the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-11 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the physician acted upon the MRR in a timely manner and according to the facility's policy. The facility failed to develop policy which addresses the monthly MRRs that include time frames for the different steps in the process for one (#26) of five residents reviewed for unnecessary medications. The Residents Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: 1. The facility's Consultant Pharmacist Reports page 220, read in part, .B. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. In the event of a problem requiring the immediate attention of the prescriber, the responsible prescriber or physician's designee is contracted by the consultant pharmacist or the facility, and the prescriber is documented on the consultant pharmacist review record or elsewhere in the resident's medical record. C. Recommendations are acted…

    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 · E2022-10-11 · tag F0801 — pattern
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure the dietary supervisor received the certified dietary manager certification within one year of employment. The Resident Census and Conditions of Residents documented 64 residents were served meals from the kitchen. Findings: On 10/05/22 at 9:47 a.m., during the initial tour of the kitchen, cook #1 was asked who the DM was for the facility. [NAME] #1 stated the DM's name and stated he was not working at that time but was supposed to come in around noon. On 10/10/22 at 10:45 a.m., a return visit to the kitchen was conducted and the DM was observed in the kitchen. On 10/10/22 at 10:48 a.m., the DM stated he had been in the DM position a little over a year. The DM was asked if he had his DM certification. The DM stated he did not. He was asked if he was attending classes. The DM stated he was not enrolled in classes for DM certification. He stated he had completed Servesafe training. On 10/10/22 at 5:57 p.m., the DM stated he had worked in the kitchen for the facility a while and was promoted to DM in April of 2021.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-11 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review,and interview, the facility failed to ensure menus were followed for the observed noon meal. Bread was not served to any resident and the mechanical soft and puree meals did not receive every item on the menu. The Resident Census and Conditions of Residents documented 15 residents had mechanically altered diet including puree and all chopped foods. Findings: On 10/05/22 at 4:32 p.m., Res #20 stated she would like to have cake, pie, cobbler, fruit, pudding, or ice cream once in a while. The facility menu for the 10/10/22 noon meal documented, Lasagna, green beans, tossed salad, bread of choice, and dessert of the day. On 10/10/22 at 11:35 a.m., the mechanical soft meal was observed. It was ground meat in sauce, no noodles were observed. On 10/10/22 at 11:49 a.m., meal service was observed. Bread was not observed on the serving line. On 10/10/22 at 11:56 a.m., cook #1 was observed to puree the mechanical soft meat sauce for the puree meal. [NAME] #1 stopped serving to make the puree. The mechanically soft meals and the puree meat diet did not get…

    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 · E2022-10-11 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food was served at a palatable temperature for three (#20, 53, and #265) of three residents reviewed for cold food. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: 1. Res #20's quarterly assessment, dated 08/05/22, documented the resident's cognition was intact. On 10/05/22 at 4:37 p.m., Res #20 stated the food was always cold in the dining room and on the halls. 2. Res #53 had diagnoses which included protein-calorie malnutrition. A quarterly assessment, dated 09/08/22, documented Res #53 was moderately impaired with cognition. On 10/05/22 at 10:15 a.m., Res #53 stated he did not like the food and it was always cold by the time it got to the room. Res #53's meal was observed with 75% of the meal left on his plate. On 10/07/22 at 1:11 p.m., the temperature of Res #53's meal was obtained. The chicken pot pie was 127 degrees F and the green beans were 103 F. 3. Res #265 had diagnoses which included protein-calorie malnutrition. On 10/05/22 at 10:10 a.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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-11 · 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 — 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 food was stored and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: On 10/05/22 at 9:47 a.m., during the initial tour of the kitchen, the following were observed. The floor in the kitchen was visible dirty. Broken tiles on the floor. Along the wall four tiles had come off the wall and were laying on the floor close to the hand washing sink. On the hand washing sink were two dirty light covers with liquid in them. The trash can was visibly dirty on the outside and the inside of the lid was visibly dirty as well. The oven were observed to have an over spill of an unidentified substance running down the inside of one of the oven doors. On 10/05/22 at 9:56 a.m., the walk in refrigerator was observed to have debris and dirt on the floor, with paper items, and a melted popsicle leaking out of the package onto the floor. Two plates covered with names of residents…

    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 · D2022-10-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 verbal abuse allegation was thoroughly investigated for one (#55) of two residents reviewed for allegations of abuse. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: The facility's abuse policy, read in part, .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident . Res #55 had diagnoses which included dementia with other behavioral disturbance and impulse disorder. A documented interview by the administrator, dated 08/08/22, read in entirety, I visited with [LPN #3 name deleted]. I told her that I was told that she [sic] hollering cursing in front of residents. She stated that she did get upset and hollered and may of said something she should not of. Stated that she was just overwhelmed with all the activity that was going on in the unit. I told her I'm going to have to suspend her. She apologized and left in tears. The verbal abuse was admitted [LPN #3 name…

    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 · D2022-10-11 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 correctly identify an individual with a mental disorder for one (#54) of one resident sampled for PASRR level I screening. The Resident Census and Conditions of Residents form documented 44 residents had documented psychiatric diagnoses. Findings: Res #54 was admitted with diagnoses which included unspecified psychosis, recurrent depressive disorders, and anxiety disorder. A OHCA PASRR level I, dated 07/12/22, documented Res #54 did not have a diagnosis of serious mental illness. An admission MDS, dated [DATE], documented Res #54 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The assessment documented Res #54 was severely impaired in daily decision making, had delusions, behaviors directed toward others daily, and wandered daily. The assessment documented the resident was independent to required extensive assistance with ADLs. The assessment…

    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 · D2022-10-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure to the extent practicable, the participation of the resident and the resident's representative in development of the resident care plan for one (#54) of one resident reviewed for participation in care planning. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: Res #54 was admitted with diagnoses which included unspecified psychosis, recurrent depressive disorders, and anxiety disorder. An admission MDS, dated [DATE], documented Res #54 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The assessment documented Res #54 was severely impaired in daily decision making, had delusions, behaviors directed toward others daily, and wandered daily. The assessment documented the resident was independent to required extensive assistance with ADLs. The assessment documented the resident had…

    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 · Dcited before2022-10-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide weekly wound assessments for one (#20) of one resident sampled for non-pressure wounds. The Resident Census and Conditions of Residents form documented three residents with pressure ulcers. Findings: Res #20's admission MDS assessment, dated 11/14/21, documented the resident was independent with ADLs and had one pressure ulcer on admission and one surgical wound. A physician order, dated 06/28/22, documented to cleanse sternal wound with wound cleanser, pat dry, pack Biostep AG into wound bed and undermining, apply skin prep to periwound, cover with foam bordered dressing every other day for surgical incision. A quarterly MDS assessment, dated 08/05/22, documented the resident was cognitively intact, was independent to requiring limited assistance with ADLs, had one pressure ulcer which was present on admission and one surgical wound. The current care plan, read in part, .to assess/record/monitor wound healing. Measure length, width, and depth weekly where possible. Assess and document status of wound perimeter,…

    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 · D2022-10-11 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 call light system was properly functioning for a shower room on 100 hall and a resident bathroom for Res #61. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: On 10/05/22 at 4:57 p.m., Res #61 in room [ROOM NUMBER] stated the call light in her bathroom was broken. On 10/05/22 at 4:58 p.m., a surveyor observed the call light in Res #61's bathroom to have a cord with no button to push only wires sticking out of the cord. On 10/05/22 at 3:56 p.m., the call light in the shower room on hall 100 was observed to not work. On 10/11/22 at 7:55 a.m., the maintenance supervisor stated he depended on the staff to put in a work order or text him when there were issues in areas where residents received care. He stated he did not check call lights. He said he depended on staff to inform him when there was an problem with a call light. On 10/11/22 at 8:07 a.m., the maintenance supervisor observed…

    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.

    Environmental 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 4 of 53.4+0.6 vs chain
Quality measures 3 of 53.0≈ chain avg
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 5Sequoyah Pointe Skilled Nursing And TherapyTahlequah, OK 4 of 5St. Ann's Skilled Nursing And TherapyOklahoma City, OK 4 of 5The CommonsEnid, 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, KRISTYIndividualCONTRACTED MANAGING EMPLOYEE; W-2 MANAGING EMPLOYEEsince 04/01/2020
CRANE, JOANNAIndividualW-2 MANAGING EMPLOYEEsince 12/17/2013
COBLE, WILLIAMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2020
BRIDGES ESOP, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/31/2020

CMS files one row per role, so the 7 rows in the source record cover these 5 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.

$5.1M
Net patient revenuemost recent cost report
-3.9%
Operating marginrevenue minus expenses
$432K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 2%Other / private 20%

About 78% 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 $432K 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

$248per resident / day
operating cost
$7,525per month
≈ monthly operating cost
$238per 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 375185. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-10, 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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