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Gracewood Health & Rehab

6201 East 36th Street, Tulsa, OK 74135 · For profit - Limited Liability company · 121 certified beds · (918) 622-3430 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • 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
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (76%) 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.

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

Location & what’s nearby

Urgent care / clinic
6732 East 41 St
Pharmacy
3980 S Hudson Ave · (918) 835-2112 · Call to confirm hours
Grocery
3960 S Hudson Ave · (918) 921-5364 · Call to confirm hours
Park
6135 E 32nd Pl · (918) 743-0463 · Typically dawn to dusk
Place of worship
6355 E Skelly Dr · (918) 924-6509

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.9%13.6%15.4%better
Long-stay residents who lose too much weight5.2%3.3%5.4%typical
Long-stay residents with a catheter left in their bladder2.0%1.9%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.1%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 injury6.0%4.7%3.3%worse
Long-stay residents whose ability to walk worsened8.1%13.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.0%25.7%18.9%typical
Long-stay residents given the seasonal flu vaccine97.6%94.6%95.3%typical
Long-stay residents with pressure ulcers3.7%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control6.1%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table33.8%17.5%17.1%worse
Long-stay hospitalizations per 1,000 resident days3.542.311.67worse
Long-stay outpatient ER visits per 1,000 resident days2.672.961.80worse

* 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.

0.16U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
<0.01hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a 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 identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 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

0.36
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.89
Aide hours/ resident / day
3.92
Total nurse hours/ resident / day
0.31
RN hoursweekends
76.2%
Total nursing turnover
80.0%
RN turnover

How full it usually is: this home is certified for 121 beds and averages 70.4 residents a day — about 58% occupied, or roughly 51 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 3.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.89 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 3.73 hrs/resident/day on weekends vs 4.00 on weekdays — 7% thinner on weekends. RN hours go from 0.38 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 76% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

5
deficiencies at the latest standard inspection (2026-04-06)
14
at the previous standard inspection (2025-01-14)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2026-04-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a resident was not physically abused by another resident for 1 (#79) of 4 sampled residents reviewed for abuse.The administrator identified 69 residents resided in the facility.A Resident to Resident Incidents policy, dated 01/2024, read in part, Upon admission to the facility, each person will be assessed through the MDS process to determine if they are at risk for abusing others.Care plans will address interventions designed to prevent occurrences.An Oklahoma State Department of Health final report, dated 05/11/25, showed a staff member witnessed Resident #79 pour water on Resident #61. Resident #61 then pushed Resident #79 causing them to fall. Resident #79 was sent to the hospital.An undated nurse note showed that around 5:30 p.m., Resident #79 was found yelling and was on the ground in the smoking area. Resident #79 stated Resident #61 pushed them down. The note showed, We tried to get [Resident #79] up but [Resident #79] said [they] could not get up as [they] were in great pain. The note showed Resident #61…

    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 · F2026-04-06 · 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: a. food items were properly sealed, dated, and labeled; b. bulging containers were removed from circulation in the dry storage; c. ensure food preparation utensils were stored in a clean environment; and d. ensure areas near food preparation were clean and free from pests, including a microwave for resident use.The administrator identified 69 residents ate meals from the kitchen.Findings: On 03/31/26 at 10:15 a.m., kitchen utensils were observed to hang over the sink where dirty dishes were to be washed.On 03/31/26 at 10:18 a.m., the following items were observed in the refrigerator:A bag of square brown patties was observed with no label or date,a pitcher of orange liquid was observed with no label or date, a bag of chunks of meat with no label or date, a bag of tan circular patties was observed in an unsealed plastic bag with no label or date, anda cookie sheet of seven sandwiches was observed in the refrigerator with a date of 03/30/26 on the saran wrap, but the saran wrap was not sealed around 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 · E2026-04-06 · 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 and interview the facility failed to:a. ensure a safe and sanitary kitchen floor, b. residents were not served meals on paper products, andc. ensure hot water was available in their restroom for 1 (#21) of 17 sampled residents reviewed for access to hot water in their restroom. The administrator identified 69 residents ate from the kitchen. Findings: On 03/31/26 at 10:18 a.m., the tile floor between the two sinks on opposite sides of the kitchen was observed to have been ripped up and was filled in with gravel. On 03/31/26 at 11:01 a.m., [NAME] #2 stated All I can do is wipe down and sanitize as much as I can. A pipe busted that is what caused the flood and why the floor is busted and filled in with gravel.On 03/31/26 at 11:41 a.m., [NAME] #1 stated the floor had been filled in with gravel for a year since the flood happened. They stated they did the best they could to keep the floor clean.On 03/31/26 at 12:15 p.m., the food was observed to be plated onto paper plates. Plastic silverware was also observed.On 03/31/26 at 12:36 p.m., Resident # 21's restroom hot…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-06 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide a SNF ABN to 2 (#10 and #37) of 3 sampled residents reviewed for beneficiary notices. The administrator identified four residents discharged from the facility with Medicare benefit days remaining. Findings:1.A SNF Beneficiary Protection Notification Review form, showed Resident #10 was admitted to the facility on skilled services on 01/28/26, discharged from skilled services on 03/27/26, and remained in the facility.A SNF Beneficiary Protection Notification Review form, showed an ABN was not provided to the resident/representative.2.A SNF Beneficiary Protection Notification Review form, showed Resident #37 was admitted to the facility on skilled services on 12/29/25, discharged from skilled services on 03/27/26, and remained in the facility.A SNF Beneficiary Protection Notification Review showed an ABN was not provided to the resident/representative.On 04/06/26 at 2:12 p.m., LPN #2 stated they were not aware they had to have an ABN form if they remained in the facility after they were discharged from skilled…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure behaviors were addressed in the care plan for 1 (#61) of 17 sampled residents reviewed for care plans.The administrator identified 69 residents resided in the facility. An Oklahoma State Department of Health final report, dated 05/11/25, showed a staff member witnessed Resident #79 pour water on Resident #61. Resident #61 then pushed Resident #79 causing them to fall. An annual assessment, dated 02/23/26, showed Resident #61 had diagnoses which included bipolar, PTSD, depression, and anxiety. The assessment showed Resident #61 had a BIMS score of 12 which indicated moderate cognitive impairment. A nurse's note, dated 03/06/26, showed Resident #61 became upset when they were unable to go smoke during a tornado warning. Resident #61 threw water in the hall and onto another resident. A nurse's note, dated 03/07/26, showed Resident #61 tried to steal cigarettes from the bucket at the nurses station with the LPN at the desk. When Resident #61 was told to stop, they kicked the bucket, and grabbed the nurses forearm.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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-06 · 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 observation, record review, and interview, the facility failed to ensure adequate supervision to prevent an elopement for 1 (#20) of 2 sampled residents reviewed for elopement.The administrator identified 21 residents resided in the memory care unit.Findings:On 03/31/26 at 11:29 a.m., Resident #20 was observed resting in bed with their eyes closed. No elopement behaviors were observed. On 04/01/26 at 9:37 a.m., Resident #20 was observed resting in bed with their cover pulled up over their head. No elopement behaviors were observed. On 04/01/26 at 1:55 p.m., Resident #20 was observed walking out of their room in their pajamas. Res #20 was pleasant and easily redirected to their room by staff to get dressed. No elopement behaviors were observed. An undated face sheet showed Resident #20 admitted to the facility with diagnoses which included Alzheimer's, dementia, protein-calorie malnutrition, and hypertension. An Elopement Risk Assessment, dated 01/09/26, showed Resident #20 was not an elopement risk. An admission assessment, dated 01/19/26, showed Resident #20 did not…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-04-06 · 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 (#11) of 1 sampled resident with a PEG tube observed during medication administration.The DON identified two residents had PEG tubes.Findings:On 04/01/26 at 2:00 p.m., LPN #1 was observed during administration of medications to Resident #11 through their PEG tube. LPN #1 was not observed to have utilized PPE, except for gloves. Signage indicating EBPs and required PPE was not observed near the resident's room. The Enhanced Barrier Precautions policy, dated August 2022, read in part, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents.EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tube .) .Signs are posted on the door or wall outside the resident room indicating the type…

    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 · E2025-01-14 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 were provided with privacy curtains. The administrator identified 78 residents resided at the facility. Findings: A Bedrooms policy, reviewed May 2024, read in part, Each room is designed to provide full visual privacy for each resident (in the form of ceiling suspended curtains that extend around the bed) and equipped for adequate nursing care On 01/06/25 at 4:26 p.m., room [ROOM NUMBER] was observed to have no privacy curtain. Resident #24 stated there was no privacy and all activities other than using the restroom were completed in full view of their roommate. On 01/07/25 at 11:52 a.m., room [ROOM NUMBER] was observed to have no privacy curtain. The room had two residents residing in the room. On 01/09/25 at 10:44 a.m., LPN #3 stated a curtain should be in room [ROOM NUMBER] to provide privacy and they did not know why one was not installed. On 01/09/25 at 11:09 a.m., the DON stated one of the resident's in room [ROOM…

    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 · E2025-01-14 · 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 four (#18, 22, 26, and #42) of four sampled residents who were reviewed for activities. The administrator identified 78 residents who resided at the facility. Findings: An Activity Programs policy, revised August 2024, read in parts, Activity programs designed to meet the needs of each resident are available on a daily basis .designed to encourage maximum individual participation and are geared to the individual resident's needs .are scheduled 7 (seven) days a week. 1. Resident #18 had diagnoses which included chronic pain, obesity, and limited mobility. On 01/06/25 at 11:18 a.m., Resident #18 stated they could not go to activities because they did not have a wheelchair that worked. They stated the bottom of the wheelchair had a hole in it and was not comfortable, so they did not get up much. On 01/07/25 at 3:46 p.m., CNA #1 stated they did not know if activities were offered or not. On 01/07/25 at 3:47 p.m., RN #1 stated there was an activities person, but they did not…

    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 · E2025-01-14 · 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 pharmacist medication regimen reviews were conducted monthly for five (#24, 57, 62, 22, and #59) of five sampled residents who were reviewed for unnecessary medications. The DON identified 78 residents who received medications in the facility. Findings: The Medication Regimen Reviews policy, dated May 2024, read in parts, The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports .Copies of medication regimen review reports .are maintained as part of the permanent medical record. 1. Resident #24 had diagnoses which included schizoaffective disorder, bipolar type. The Care Plan, dated 12/09/24, read in part, Monitor pharmacist's drug regimen review for identification of potential drug interactions. Review of the clinical record and the monthly medication regimen reviews provided by the DON did not reveal the pharmacist 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to: a. ensure medications were secured for one (300 hall treatment cart) of six medication carts observed; b. ensure medications were dated when opened and/or insulin was discarded after 28 days for two (200 hall treatment cart and 300 hall treatment cart) of three medication carts observed; and c. ensure expired medications were not in use for one (100 hall medication cart) of three medication carts observed. LPN #2 identified six medication carts in the facility. Findings: The Medication Storage policy, dated 07/21/24, read in parts, The facility shall not use .outdated .drugs or biologicals .Compartments (including .carts .) shall be locked when not in use. 1. On 01/07/25 at 4:34 p.m., RN #2 was observed during medication administration to prepare insulin and enter room [ROOM NUMBER]. The 300 hall treatment cart was observed to be left unattended and unlocked. On 01/07/25 at 4:35 p.m., RN #2 was observed to walk to the nurses station to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2025-01-14 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 resident records were complete and accessible for four (#57, 24, 22, and #59) of 18 sampled residents whose records were reviewed. The DON identified 78 residents who resided in the facility. Findings: The Medication Orders policy, dated 06/15/24, read in part, A current list of orders must be maintained in the clinical record of each resident. The Charting and Documentation policy, dated July 2024, read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1. Resident #57 had diagnoses which included unspecified dementia. Review of the clinical record revealed the last gradual dose reduction from the consultant pharmacist was dated 2023, the latest lab report was dated 11/28/23, and the physician's…

    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 before2025-01-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for one (#279) of one sampled resident with a peg tube observed during medication administration. The nurse manager identified two residents who had peg tubes. Findings: The Enhanced Barrier Precautions policy, dated August 2022, read in parts, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tube .) .Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required .PPE is available outside of the resident rooms. Resident #279 had diagnoses which included unspecified severe protein calorie malnutrition. The significant change assessment, dated 05/27/24, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-14 · tag F0919 — failed to provide a working call system — pattern
    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, record review, and interview, the facility failed to ensure call lights were operational and available for residents. The administrator identified 78 residents who resided at the facility. Findings: A Bedrooms policy, reviewed May 2024, read in part, All resident rooms are equipped with a resident call system that allows residents to call for staff assistance. Review of the maintenance log book revealed on 12/28/24 room [ROOM NUMBER] had a call light ripped from the wall and wires were exposed. The log book documented the date of repair was 12/30/24. The repair was initialed. On 01/08/25 at 11:36 a.m., room [ROOM NUMBER] was observed to have wires coming from the wall where the call light would be. On 01/06/25 at 10:15 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:16 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:18 a.m., room [ROOM NUMBER]A was observed to have no call light cord. On 01/06/25 at 10:19 a.m., room…

    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
  • Potential for harm · Dcited before2025-01-14 · 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 ensure nail care was provided for one (#57) of one sampled resident who was reviewed for ADL care. The nurse manager identified 56 residents who were dependent on staff for nail care. Findings: The Fingernails/Toenails, Care of policy, dated February 2024, read in parts, The purposes of this procedure are to clean the nail bed, to keep nails trimmed .Nail care includes daily cleaning and regular trimming .Documentation .If the resident refused the treatment, the reason(s) why and the intervention taken .Notify the supervisor if the resident refuses the care. Resident #57 had diagnoses which included unspecified dementia. The Care Plan, updated 11/04/24, documented the resident required varied levels of assistance with ADLs due to weakness. The Activity of Daily Living Record, dated December 2024, documented the resident had been offered and/or received nail care five times, including refusals of nail care, out of 93 opportunities. The Activity of Daily Living Record, dated 01/01/25 through 01/07/25,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · 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 observation, record review, and interview, the facility failed to monitor and evaluate a resident's response to an intervention for one (#26) of one sampled resident who was reviewed for quality of care. The administrator identified 78 residents who resided at the facility. Findings: An Abuse Policy and Procedure policy, dated January 2024, read in parts, nursing staff shall document the incident and interventions in the Medical Record .Nursing Assessment. The Director of Nursing or designee is responsible for assessing the victim and shall document findings .in the medical record. Resident #26 had diagnoses which included vascular dementia, Alzheimer's disease, and delusions. Review of the care plan for Resident #26, dated 01/03/23 and updated 04/01/24, 07/01/24, and 07/25/24, documented a concern for alteration in skin due to incontinence and documented to monitor and notify physician and representative of changes such as bruising. The care plan revealed no concern regarding bruising through the review dates. On 01/06/25 at 11:52 a.m., Resident #26 was observed to have 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 · D2025-01-14 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents were assessed for the use of bed rails for one (#57) of one sampled resident who was reviewed for bed rails. The DON identified one resident who had bed rails. Findings: The Proper Use of Side Rails policy, dated December 2022, read in parts, Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents .When used for mobility or transfer, an assessment will include a review of the resident's .bed mobility .risk of entrapment from the use of side rails .that the bed's dimensions are appropriate for the resident's size and weight .Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails .The risks and benefits of side rails will be considered for each resident .Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. Resident #57 had diagnoses which included unspecified…

    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 · D2025-01-14 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure nurse staffing was posted for public view. The administrator identified 78 residents resided at the facility. Findings: A review of the QOC reports for October, November and December 2024 revealed staffing numbers were good with the exception of one day shift in December. On 01/14/25 at 9:20 a.m., the administrator stated they had the staff names and position for each shift on each hall. They stated they did not have the total number of nursing hours posted. On 01/14/25 at 10:32 a.m., the DON stated they had a book for the daily schedule at the nurses desk, but for the time during the survey the book was in their office. They stated total nursing hours were not in the book.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents did not receive unnecessary medications for one (#22) of five sampled residents who were reviewed for psychotropic medications. The nurse manager identified 78 residents who received medications. Findings: Resident #22 had diagnoses which included Alzheimer's/dementia, anxiety and depression. A review of the clinical record for Resident #22 did not document side effect monitoring or that the physician was provided an MRR or GDR of Risperdal (risperidone) (an antipsychotic) for review and reduction. A Care Plan, dated 07/10/24, for Resident #22 documented a concern for psychotropic drug use and was updated/reviewed 10/08/24. The care plan revealed Resident #22 was taking an antipsychotic Nuedexta, an antidepressant trazodone, and an anti-anxiety medication of Ativan. The care plan was not updated to include Risperdal. The care plan documented approaches to evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. On 01/09/25 at 11:48 a.m., the DON was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for two (#24 and #62) of five sampled residents whose labs were reviewed. The DON identified 78 residents who had orders for labs. Findings: The Lab and Diagnostic Test Results - Clinical Protocol policy, dated July 2024, read in part, The staff will process test requisitions and arrange for tests. 1. Resident #24 had diagnoses which included schizoaffective disorder, bipolar type. A Physician's order, dated 02/05/21, documented to obtain a valproic acid level every 3 months in July, October, January, and April. A Physician's order, dated 11/01/23, documented the resident was ordered valproic acid 500 mg at bedtime. Review of the clinical record and labs provided by the DON did not reveal a valproic acid level had been obtained in July 2024 or October 2024. 2. Resident #62 had diagnoses which included vascular dementia. A Physician's Order, dated 02/12/24, documented to obtain a CMP every six months. Review of the clinical record and lab results provided by the DON…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · tag F0909 — failed to maintain a comfortable temperature — isolated
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    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 beds were regularly inspected for safety for one (#57) of one sampled resident who was reviewed for bed rails. The DON identified one resident who had bed rails. Findings: The Bed Safety policy, dated June 2024, read in parts, Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks .Ensure that bedrails are properly installed. Resident #57 had diagnoses which included unspecified dementia and hemiparesis of the left side. Review of the clinical record and maintenance logs did not reveal documentation the resident's bed had been regularly inspected for safety related to the use of side rails. On 01/06/25 at 9:49 a.m., Resident #57 was observed in bed with half bedrails in the up position bilaterally. On 01/13/25 at 10:01 a.m., the DON stated the maintenance staff inspected beds and bed rails for safety. On 01/13/25 at 10:12 a.m., maintenance worker #1 stated 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-03 · tag F0839 — widespread
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    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 staff was licensed in accordance with applicable State laws. The DON identified 78 residents who resided in the facility. Findings: On [DATE] at 12:45 p.m., RN #1 was observed at the nurse station. They stated they were working as the charge nurse for the shift. An employee record documented RN #1 had a valid RN license for the state of Texas. There was no record for a valid RN license for the state of Oklahoma. On [DATE] at 10:50 a.m., the administrator reviewed RN #1's employee file noting a Texas RN license. The administrator stated per documentation found on the Oklahoma Board of Nursing website, RN #1's Oklahoma RN license had expired on [DATE]. On [DATE] at 11:10 a.m., the DON stated RN #1 had worked full time hours in the facility since [DATE] with one break in full time status for the month of [DATE]. The DON stated the RN continued full time working status from [DATE] to current. The DON stated they did not know the RN's…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-13 · 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 record review and interview, the facility failed to ensure assistance with showers was provided for one (#1) of three reviewed for bathing. The DON identified 52 residents who required assistance with bathing. Findings: Resident #1 admitted with diagnoses which included arthropathy, morbid obesity, and cellulitis. On 11/08/23 at 1:32 p.m., Resident #1 stated they were not getting their showers on Monday, Wednesday, and Friday, and had never received three showers in a week. Resident #1 stated they had only had a handful of showers in October. The shower list in the shower book for Hall 200, documented Resident #1 was to receive a shower on the second shift every Monday, Wednesday and Friday. The Activity of Daily Living Record, dated October 2023, documented Resident #1 had received five showers out of 13 opportunities. Review of the shower sheets revealed no refusals in October from Resident #1. In the month of October there were three shower sheets completed. One for 10/13/23, one for 10/16/23, and one for 10/23/23. The 10/23/23 shower sheet documented Resident #1 was in…

    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 before2023-09-28 · 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 observation, record review, and interview, the facility failed to implement interventions to prevent future falls and failed to update the resident's care plan for one (#21) of one resident reviewed for falls. Findings: Resident #21 had diagnoses which included Alzheimer's disease. An Incident/Accident Report, dated 06/01/23 documented the resident was found on the floor with redness to right eyelid, a swollen upper lip, and bled from an abrasion on the right side of their forehead. An FSI - Fall Scene Investigation Report, dated 06/01/23, documented the resident rolled out of bed and was found on the floor next to their bed. The report documented the CNA performed rounds every two hours. The initial interventions to prevent future falls were lowered bed, non-skin socks, floor mat, and frequent checks. A significant change assessment, dated 07/11/23, documented the resident was severely impaired in cognition and displayed continuous inattention, disorganized thinking, and wandering. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-23 · 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 proper infection control measures were followed during peg tube care for one, (#4) of two residents sampled for peg tube care. The Resident Census and Conditions of Residents report, dated 08/21/23 documented two residents with peg tubes. Findings: Resident #4 had a diagnosis which included dysphasia. On 08/21/23 at 11:30 a.m., Resident #4 was observed lying supine. LPN #1 was observed to provide peg tube care for resident #4. LPN #1 donned gloves, uncovered the resident's abdomen and removed a dressing around the peg tube, dated 08/17/23. LPN #1 cleansed the area around the peg tube with sterile saline. LPN #1 did not clean their hands prior to donning gloves and providing care. Without changing gloves and sanitizing hands LPN #1 applied clean gauze around the peg tube, secured it with tape, and wrote the date on the tape. LPN #1 then removed their gloves and washed their hands. LPN #1 was asked what the policy was for handwashing related to peg tube care. LPN #1 stated, before putting on gloves you…

    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

“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 BRADFORD MONTGOMERY — 11 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 2 of 52.2-0.2 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.4+0.6 vs chain
Quality measures 2 of 52.9-0.9 vs chain
The other 10 homes this chain runs (chain average 2.2★, per CMS)

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
MONTGOMERY, BRADFORDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/31/2015
POPPELL, CONNIEIndividualW-2 MANAGING EMPLOYEEsince 10/31/2015

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.

$5.2M
Net patient revenuemost recent cost report
+1.2%
Operating marginrevenue minus expenses
$232K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 3%Other / private 19%

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 $232K 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

$196per resident / day
operating cost
$5,967per month
≈ monthly operating cost
$199per 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 375438. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-06, 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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