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Heritage Skilled Nursing And Therapy

201 West Walnut, Tecumseh, OK 74873 · For profit - Limited Liability company · 100 certified beds · (405) 598-2167 Medicare & Medicaid certified

Call the home — (405) 598-2167 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0568)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

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 mishandling residents’ money or property (F0568)
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • nursing-staff turnover (60%) runs well above the national median (45%)

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

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

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 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
418 E Walnut St · (405) 598-6595 · Call to confirm hours
Pharmacy
211 N Broadway St · (405) 598-3729 · Call to confirm hours
Grocery
214 E Walnut St · (405) 598-2012 · Call to confirm hours
Park
515 N 3rd St · Typically dawn to dusk
Place of worship
117 N Broadway St · (405) 412-8411

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 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 rating5★
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 increased6.8%13.6%15.4%better
Long-stay residents who lose too much weight2.9%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 infection0.4%2.8%2.0%better
Long-stay residents with depressive symptoms4.5%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 injury7.0%4.7%3.3%worse
Long-stay residents whose ability to walk worsened6.8%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.4%25.7%18.9%better
Long-stay residents given the seasonal flu vaccine98.4%94.6%95.3%typical
Long-stay residents with pressure ulcers5.7%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control21.7%17.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.0%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication3.8%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine85.7%74.1%79.4%typical
Long-stay hospitalizations per 1,000 resident days1.842.311.67typical
Long-stay outpatient ER visits per 1,000 resident days2.652.961.80worse

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.

54.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.3%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
0.12U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 SNF54.3%CMS range 40.3–65.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.9–15.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 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 worsened14.3%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 hospitalization6.8%CMS range 3.8–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 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

0.28
RN hours/ resident / day
1.07
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.26
RN hoursweekends
60.0%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 63.6 residents a day — about 64% occupied, or roughly 36 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.28 hrs/resident/day on weekends vs 3.68 on weekdays — 11% thinner on weekends. RN hours go from 0.28 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%.

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

6
deficiencies at the latest standard inspection (2025-03-27)
10
at the previous standard inspection (2023-11-16)

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · E2025-03-27 · tag F0656 — failed to write and follow a full care plan — pattern
    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 — 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 develop comprehensive care plans for 2 (#24 and #38 ) of 19 resident care plans reviewed. The administrator identified 65 residents resided in the facility. Findings: 1. Resident #24 was admitted to the facility on [DATE] with diagnosis of displaced fracture of upper end of left humerus. The admission (comprehensive) assessment was completed on 02/28/25. Care areas that were triggered (potential areas of concern) during the comprehensive assessment included: cognitive loss/dementia, ADL function, urinary incontinence, and psychoactive drug use. The care plan did not include cognitive loss, ADL function, urinary incontinence, or psychoactive drug use when reviewed on 03/25/25. The care plan should have been completed by 03/07/25. The Resident Assessment Instrument (RAI) guidelines state the comprehensive care plan should be completed by admission assessment completion plus seven days, and no later than the admission date plus 21 days. On 03/25/25 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-27 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 bottles containing tube feeding were labeled and dated for 2 (#30 and #215 ) of 2 sampled residents observed for tube feeding. The administrator identified three residents required tube feedings. 1. On 03/26/25 at 7:48 a.m., the tube feeding for Resident #30 was observed running at 60 ml/hr. The bottle was not labeled with the date or time opened, or who hung the bottle. A Tube Feeding policy, dated 06/24/10, read in part, Change and label (name of resident, date, and time) feeding set (tubing and appropriate syringe) every 24 hours. Resident #30 admitted to the facility with diagnoses which included dysphagia, diabetes mellitus, major depressive disorder, chronic pain, and cerebral infarction. A physician order, dated 10/14/24, read in part, one time a day Diabetisource AC 1250ml 60ml/hr x 21 hours flush at 35ml/hr over 21 hours AND one time a day turn feeding off at 9am on at noon AND every shift Diabetisource AC 60ml/hr x 21 hours document amount of formula only AND every shift flush 35ml/hr x 21…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 protected health information was secure for 1 (#66) of 65 residents receiving care in the facility. The administrator identified 65 residents resided in the facility. Findings: On 03/26/25 at 12:24 p.m., a computer on a cart by the nurses station for the North and Northeast halls was observed to be open and showed protected health information for Resident #66. There were no residents or staff around at that time. A Resident's Records policy in the admission agreement, dated 10/14/19, read in part, Information included in the resident's medical records is confidential. Unauthorized persons shall not be allowed to review these records without the Resident's written consent except as required or permitted by law. On 03/26/25 at 12:27 p.m., the ADON returned to the cart and stated they were busy collecting a Vanco trough (antibiotic lab draw) and had just forgotten to close the screen out. They stated they knew it was a violation of Health Insurance Portability and Accountability Act (HIPPA). On 03/27/25…

    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 · Dcited before2025-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to monitor and intervene for a PICC line that required care for 1 (#215 ) of 2 sampled residents with PICC lines. The administrator identified 65 residents resided in the facility and two residents had PICC lines. Findings: On 03/26/25 at 12:18 p.m., a PICC line to Resident #215's left shoulder was observed with a dressing that had a date of 03/16/25 on it. There was brown drainage noted under the clear dressing. Resident #215 was admitted on [DATE] with a diagnosis of encephalopathy and severe sepsis with septic shock. An IV [intravenous therapy] Nursing Policies and Procedures policy, dated 06/01/11, read in part, Sterile dressing changes will be performed every 7 days and immediately if the integrity of the dressing is compromised. On 03/26/25 at 12:27 p.m., the ADON stated they were trying to get orders to discontinue the PICC line. They stated the policy was to change the dressing within 24 hours after being placed and then every 72…

    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 · D2025-03-27 · tag F0732 — isolated
    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 post nurse staffing in a prominent place accessible to residents and visitors. The administrator identified 65 residents who resided in the facility. Findings: On 03/25/25 at 8:00 a.m., no staffing board was observed in the facility. On 03/26/25 at 9:15 a.m., no staffing board was observed in the facility. On 03/26/25 at 10:58 a.m., the director of nursing pointed out a schedule on a cork board behind the nurses desk. Only half of the schedule was seen.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · 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 infection control practices were followed for glove usage. The administrator identified 65 residents resided at the facility. Findings: On 03/25/25 at 11:12 a.m., RN #1 was observed wearing gloves and getting a finger stick blood sugar of a resident. RN #1 then changed gloves and gave the resident their insulin. They did not sanitize their hands between glove changes. On 03/25/25 at 11:15 a.m., RN #1 was observed still wearing the same gloves out in the hall to get the sanitizing wipes from the nurses' cart. RN #1 cleaned the glucometer and then removed their gloves. A Personal Protective Equipment policy, dated 03/02/24, read in part, Gloves can protect both patients and healthcare personnel from exposure to infectious materials that may be carried on hands. During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from 'clean to dirty' and confining or limiting contamination to surfaces that are directly needed for patient care. On 03/25/25 at…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-16 · 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

    Based on observation and interview, the facility failed to ensure the kitchen and dining area were kept clean and maintained in good repair. The DM identified 67 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: On 11/13/23 at 7:33 a.m., a tour of the kitchen was conducted. The following observations were made: a. there was a hole in the wall around the piping below the dish machine, b. ceiling lights were burned out and/or not working. End caps were missing on the light shields, c. there was an accumulation of black residue on the floor and the walls below and behind the dish machine and cook area, and d. there was food splatter on the ceiling above the three compartment sink. On 11/14/23 at 1:19 p.m., a tour of the kitchen and dining area was conducted. The following observations were made. a. there was black residue and multiple rodent droppings inside of the cabinets in the drink station area. There were holes, trim missing, and cabinet material was peeling off of the cabinets, and b. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-16 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 the resident or their legal representative received education regarding the benefits and potential side effects of the influenza immunization and obtain consents before administering the immunization for three (#46, 49, and #55) of five sampled residents reviewed for immunizations. The DON identified 69 residents resided in the facility. Findings: The facility's Influenza Vaccination Program policy, revised on 10/11/05, read in parts, .It is the policy of this facility to provide all residents .who do not have allergy to the vaccine, the influenza vaccination yearly .obtain consent forms .Provide education to residents or resident representative on the benefits and potential side effects of the influenza vaccine .before administering the vaccine . 1. Res #55 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, diabetes mellitus, GERD, hyperlipidemia, HTN, and chronic pain. A influenza immunization record,…

    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 · D2023-11-16 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    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 record review and interview, the facility failed to ensure quarterly financial statements were provided in writing to the resident and/or their representative for one (#61) of one sampled resident reviewed for personal funds. The BOM identified 34 residents who had trust accounts. Findings: Res #61 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction effecting left side, and major depressive disorder. A court document, dated 11/07/22, documented the resident had a legal guardian. A quarterly resident assessment, dated 08/06/23, documented the resident's cognition was intact. On 11/13/23 at 9:29 a.m., Res #61 stated they had a trust account and did not know how much money they had. They stated staff did not tell them anything. They stated they had to ask how much money they had. A resident trust account legers, dated 11/14/23, documented the resident had a trust account. There was no documentation the resident and/or their legal…

    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 · D2023-11-16 · 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 ensure resident care equipment was maintained in good repair for one (#61) of one sampled resident observed for resident care equipment. The DON identified 69 residents resided in the facility. Findings: Res #61 had diagnoses which included morbid obesity. A quarterly resident assessment, dated 08/06/23, documented the resident's cognition was intact. On 11/13/23 at 9:29 a.m., the resident stated their mattress was old and torn. They stated staff were aware. Their bed was made and the mattress could not be seen. On 11/15/23 at 10:16 a.m., the resident's mattress was observed with CNA #1. The bottom of the mattress had multiple large tears. The CNA was asked if they were aware the resident's mattress was torn. They stated they were not. They stated if a residents mattress was in bad repair they would report it to the charge nurse and maintenance. On 11/15/23 at 10:28 a.m., LPN #2 was asked if they were aware the resident's mattress was torn. They stated they were not aware. They were asked what was the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2023-11-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide assistance with eating for a dependent resident for one (#30) of five sampled residents who were reviewed for activities of daily living care. The DON identified four residents who required assistance with eating. Findings: Res #30 had diagnoses which included blindness right eye, anorexia nervosa, senile degeneration of brain, severe protein-calorie malnutrition, lack of coordination, muscle wasting, atrophy, stroke, and vitamin deficiency. An annual assessment, dated 12/07/22, documented the resident required moderate assistance with eating which included oversight, encouragement, or cueing, and was severely cognitively impaired. A quarterly assessment, dated 09/07/23, documented the resident required moderate assistance with eating which included oversight, encouragement, or cueing, and was severely cognitively impaired. On 11/13/23 at 7:38 a.m., the resident was observed in their bed asleep, with their breakfast plate on the over-the-bed table in front of them. The resident had not been adjusted…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents with limited range of motion received restorative services and/or assistance to prevent further decrease in range of motion for two (#30 and #220) of two sampled residents reviewed for mobility. The DON identified 6 residents with impaired range of motion. Findings: A facility policy dated 10/01/2001, titled Range of Motion, read in part .Active or passive range of motion is done to reduce muscle wasting, weakening, and prevents or reduces the development of contractures. EQUIPMENT: Adaptive equipment or supportive devices as ordered by the physician and part of the plan of care . 1. Res #30 was admitted to the facility on [DATE] and had diagnoses which included blindness right eye, senile degeneration of brain, lack of coordination, muscle wasting, atrophy, and stroke. A baseline assessment and care plan, dated 11/06/19, documented Res #30's weight bearing ability as full weight bearing. An annual assessment, 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 · D2023-11-16 · 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 perform ongoing assessments and oversight of the resident prior to and after dialysis treatments for one (#56) of one sampled resident who received dialysis. The DON identified 69 residents resided in the facility. Findings: Res #56 had diagnoses which included end stage renal disease, diabetes with chronic kidney disease, hypertensive heart, chronic kidney disease with heart failure stage five, and dependence on renal dialysis. A physician order, dated 01/19/23, documented the resident was to receive dialysis treatments Tuesday, Thursday, and Saturday at 11:30 a.m. A physician order, dated 01/19/23, documented to remove AVF dressing four hours after dialysis treatment. If access is still bleeding after dressing removal, re-apply sterile gauze to area using slight pressure to stop bleeding. A physician order, dated 01/19/23, documented check AVF for thrill and bruit every shift. If absent notify physician. A physician order, dated 01/19/23, monitor AVF for signs and symptoms of trauma and/or infection every shift. 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 · D2023-11-16 · tag F0755 — failed to provide safe pharmacy services — isolated
    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

    Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#15) of five sampled residents reviewed for medications. The DON identified 69 residents resided in the facility. Findings: Res #15 had diagnoses which included major depressive disorder. A physician order, dated 04/25/23, documented venlafaxine HCL (an antidepressant) 75 mg three times a day. The October 2023 MAR and order administration notes documented venlafaxine was not administered 17 out of 68 opportunities. It was documented the medication was not in the facility. On 11/16/23 at 10:45 a.m., CMA #3 was asked what was the protocol for reordering medications. They stated the medication card indicated when the medication was to be reordered. They stated they were to notify the nurse and call the pharmacy if medications had not been received. On 11/16/23 at 10:52 a.m., the DON was asked what was the protocol for reordering medications. They stated the medication card indicated when to reorder. They stated staff were to reorder seven days prior to the medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure labs were not collected without a physician order for one (#55) of five sampled residents reviewed for lab services. The DON identified 69 residents resided in the facility. Findings: Res #55 had diagnoses which included diabetes mellitus, deficiency of other vitamins, and HTN. A lab report, dated 07/05/23, documented a CBC, CMP, and HbA1c were collected. There was no physician order to collect the labs. On 11/15/23 at 2:22 p.m., the DON was asked if there was a physician order to collect the labs for the resident. On 11/15/23 at 2:30 p.m., the DON stated the physician order to collect the labs did not get reactivated when the resident returned from the hospital in February. They stated there were standing orders to collect the labs.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · 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 wrist blood pressure monitors were cleaned in between residents for two (#50 and #57) of two residents observed during medication administration. The DON identified 69 residents who resided in the facility. The facility's Infection Control policy, dated 06/23/17, read in parts, .Medical equipment and instruments/devices must be cleaned and maintained according to the manufactures' instructions to prevent patient-to-patient transmission of infectious agents . On 11/15/23 at 8:02 a.m., CMA #3 obtained Res #57's blood pressure with a wrist blood pressure monitor, after obtaining the blood pressure, CMA #3 removed the device from the resident's wrist and placed the wrist blood pressure monitor on their wrist without cleaning the blood pressure cuff. On 11/15/23 at 8:15 a.m., CMA #3 removed the wrist blood pressure monitor from their wrist and placed it on Res #50's wrist, without cleaning the device, after the CMA obtained the resident's blood pressure, they placed the wrist blood pressure monitor on Res…

    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 · E2022-11-17 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to: a. update the comprehensive care plan with an intervention following a fall for one (#35) of three residents reviewed for falls and b. invite the resident or resident's representative to participate in developing the care plan for one (#22) of 17 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Res #35 had diagnoses which included senile degeneration of brain, dementia, ventricular tachycardia, COPD, heart failure, and hypertension. An annual MDS, dated [DATE], documented the resident was severely cognitively intact, required extensive assist of one staff with most ADL's, and was always incontinent of bowel and bladder. A fall incident report, dated 10/10/22 at 2:45 p.m., documented an intervention to toilet the resident before lying her down for bed. A fall care plan, revised on 11/14/22, did not document the intervention from 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 before2022-11-17 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    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, observation, and interview, the facility failed to ensure a resident with limited range of motion received services to increase, maintain, or prevent further decline in range of motion for two (#20 and #26) of two residents reviewed for limited range of motion. The Resident Census and Conditions of Residents documented 61 residents resided in the facility. Findings: 1. Res #20 had diagnoses which included multiple sclerosis, nutritional deficiency, and recurrent depressive disorders. An admission assessment, dated 07/28/22, documented the resident was moderately cognitively impaired, did not walk, required extensive assistance with most ADLs, and had range of motion impairment in the upper and lower extremities. A care plan, dated 08/24/22, documented nursing restorative to do active assistive ROM LUE in all planes 2 repetitions of 10 and passive ROM RUE within functional limits 2 repetitions of 10, three times weekly. A physician order, dated 08/24/22, documented nursing restorative: active assistive ROM LUE in all planes 2 repetitions of 10 and passive ROM…

    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 · E2022-11-17 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to perform monitoring for anticoagulant medications for two (#9 and #42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Resident #42 had diagnoses which included Alzheimer's disease, schizoaffective disorder, dementia, shortness of breath, and edema. A physician order, dated 11/10/21, documented to administer apixaban 5 mg by mouth two times a day for shortness of breath. A five day MDS assessment, dated 08/30/22, documented the resident was severely cognitively intact, wandered daily, required supervision with most ADLs, utilized a wheelchair, was frequently incontinent of bowel and bladder, and received anticoagulant medication. On 11/16/22 at 9:41 a.m., the DON stated the anticoagulant medication did not have monitoring. She stated the resident received general monitoring for change in status and if there was an…

    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 · E2022-11-17 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure residents did not receive an as needed antianxiety medication without justification for administration for one (#39) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 14 residents received antianxiety medications. Findings: 1. Resident #39 had diagnoses which included dementia, insomnia, depression, hypertension, and anxiety disorder. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired, had no behaviors, required supervision with most ADLs, was occasionally incontinent of urine, and received anti-anxiety medications one out of seven days during the review period. A physician order, dated 09/14/22, documented to record behaviors and interventions every shift. A physician order, dated 10/03/22, documented to administer lorazepam (an antianxiety medication) 1 gm/1 ml gel topically to inner wrists every four hours as needed for…

    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 · D2022-11-17 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 send notice of transfer or discharge to a representative of the Office of the State Long-Term Care Ombudsman for two (#22 and #161) of two residents reviewed for discharge to the hospital. The DON documented four residents had discharged to the hospital in the last 30 days. Findings: 1. Res #22 had diagnoses which included Alzheimer's disease, dementia, UTI, bipolar disorder, and hypertension. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired, was independent with bed mobility; transfers; walking; and eating, required limited assistance from one staff with dressing; toilet use; and personal hygiene, required extensive assistance from two staff with bathing, and was frequently incontinent of bowel and bladder. A nurse progress note, dated 10/26/22 at 11:30 p.m., documented the resident was sent to the hospital. A nurse progress note, dated 10/27/22 at 1:57 a.m., documented the resident was being admitted . A nurse…

    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 · D2022-11-17 · tag F0641 — isolated
    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 MDS assessments accurately reflected the resident's status for two (#22 and #43) of 17 residents whose MDS's were reviewed. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual documented in part .Record the number of days a hypnotic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) . Res #22 had diagnoses which included Alzheimer's disease, dementia, insomnia, bipolar disorder, and anxiety. A physician order, dated 08/17/22, documented to administer Rozerem (a hypnotic medication) 4 mg by mouth at bed time for insomnia. A quarterly MDS, dated [DATE], documented the resident had received hypnotic medication zero out of seven days during the review period. The October 2022 MAR documented Res #22 received Rozerem 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-17 · 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 — 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 refer a resident with a new diagnosis of serious mental disorder for a level II PASARR for one (#48) of one resident reviewed for PASARR level II. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Res #48 admitted [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, anxiety disorder, and depressive disorders. On 02/08/22, Res #48 re-admitted the the facility with diagnoses which included schizoaffective disorder. A physician order, dated 02/09/22 documented to administer risperidone (an antipsychotic medication) 1 mg by mouth two times a day related to schizoaffective disorder. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired, had rejection of care one to three days during the review period, had a diagnosis of schizophrenia, and received antipsychotic medication seven out of seven days during the review period.…

    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 before2022-11-17 · 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 — the official record, unedited, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure the resident's treatment and care was in accordance with the person centered care plan and in accordance with professional standards for one (#29) of one resident reviewed. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: Res #29 had diagnoses which included parastomal hernia without obstruction or gangrene, major depressive disorder, gastro-esophageal reflux disease without esophagitis. A care plan, dated 08/24/22, documented Res #29 was a long term care resident. The care plan documented colostomy care as ordered. An admission assessment, dated 08/30/22, documented the resident was cognitively intact and required extensive assistance with ADLs. Physician's orders, dated November 2022, contained no orders for colostomy care. On 11/17/22 at 2:09 p.m., the MDS coordinator stated There should be have been orders for care and monitoring, output, and skin assessment.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to develop and implement interventions following a fall for one (#35) of three residents reviewed for accident hazards. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Resident #35 had diagnoses which included senile degeneration of brain, dementia, ventricular tachycardia, COPD, heart failure, and hypertension. A fall incident report, dated 06/28/2021 at 7:20 a.m., documented Res #35 had an unwitnessed fall without injury. The incident report documented the intervention was frequent visual checks by staff. A fall incident report, dated 09/15/2021 at 12:52 p.m., documented Res #35 had an unwitnessed fall without injury. The report did not document an intervention. A fall incident report, dated 05/2/2022 at 10:18 p.m., documented Res #35 had an unwitnessed fall without injury. The report documented the intervention was neuro-checks initiated. An annual MDS, dated [DATE],…

    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 · D2022-11-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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, it was determined the facility failed to provide sufficient fluid intake to maintain proper hydration status for one (#8) of one residents reviewed. The Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: Resident #8 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, mental disorder, and vitamin deficiency. A care plan, dated 10/24/22, recommended a daily fluid intake of 2815 cc and to monitor for signs and symptoms of dehydration. On 11/14/22 at 10:19 a.m., the resident was observed resting in bed with eyes open. The resident stated he needed something to drink, no hydration was observed at bedside. The resident stated They took my cup and they didn't bring me another one. On 11/16/22 at 9:04 a.m., the resident was observed to be clean and free of odors. There was no hydration observed at bedside. On 11/16/22 at 3:45 p.m., the resident was observed resting in bed with his eyes closed. There was no hydration…

    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 · D2022-11-17 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to obtain a physician ordered CBC lab for one (#13) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 61 residents resided in the facility. Findings: Res #13 had diagnoses which included nonrheumatic aortic valve disorder, hypertension, and kidney failure. A physician order, dated 07/28/22, documented to collect a CBC & Lipid panel yearly in July. A quarterly assessment, dated 10/15/22, documented the resident was moderately cognitively impaired, independent with most ADLs, and received anticoagulant medication. On 11/16/22 at 11:45 a.m., the corporate nurse consultant stated the CBC had not been collected in July 2022.

    Administration 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 4 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 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 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 06/30/2019
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.

$6.0M
Net patient revenuemost recent cost report
+0.6%
Operating marginrevenue minus expenses
$376K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 86%Medicare 4%Other / private 9%

About 86% 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 $376K 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
$7,543per month
≈ monthly operating cost
$250per 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 375446. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-27, 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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