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Oklahoma Memory Care Institute

3333 East 28th Street, Tulsa, OK 74114 · For profit - Limited Liability company · 56 certified beds · (918) 203-0606 Medicare & Medicaid certified

Call the home — (918) 203-0606 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 2026Resident-funds citation (F0568)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,653 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0568)
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,653 in federal fines (most recent 2025-01-29)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

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

Location & what’s nearby

Urgent care / clinic
3336 E 32nd St S · (918) 255-7246 · Call to confirm hours
Pharmacy
4150 S Harvard Ave Ste G2 · (918) 863-2731 · Call to confirm hours
Grocery
Aldi0.1 mi
2711 S Harvard Ave · (855) 955-2534 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 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 rating2★
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 increased36.8%13.6%15.4%worse
Long-stay residents who lose too much weight1.2%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 infection0.0%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 injury8.9%4.7%3.3%worse
Long-stay residents whose ability to walk worsened17.9%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication47.8%25.7%18.9%worse
Long-stay residents given the seasonal flu vaccine74.5%94.6%95.3%worse
Long-stay residents with pressure ulcers2.8%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control29.1%17.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.3%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication6.2%1.8%1.4%worse
Long-stay hospitalizations per 1,000 resident days3.142.311.67worse
Long-stay outpatient ER visits per 1,000 resident days4.482.961.80worse

* 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.

0.05U.S. median 0.31
Therapy hours / resident / day
<0.01hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 38% 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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
1.09
LPN hours/ resident / day
2.61
Aide hours/ resident / day
3.98
Total nurse hours/ resident / day
0.32
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 56 beds and averages 39.6 residents a day — about 71% occupied, or roughly 16 beds typically open. It usually has some room. 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 3.98 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 2.61 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 3.72 hrs/resident/day on weekends vs 4.08 on weekdays — 9% thinner on weekends. RN hours go from 0.26 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

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

Inspection trend

9
deficiencies at the latest standard inspection (2024-10-31)
13
at the previous standard inspection (2023-09-22)

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.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-02-11 · 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

    A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 01/30/25 related to the facility's failure to supervise and prevent a resident from elopement. The facility failed to prevent Resident #1 from eloping from the facility which had the potential to result in serious injury or harm. On 02/11/24, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent accident hazards related to elopement. The past noncompliance IJ was removed effective 01/31/25 after the facility put measures in place to prevent recurrence. On 01/31/25 compliance rounds were initiated, the quality assurance committee met, an inservice on elopement risk and documentation of hourly rounds were completed by all direct care staff, outside window locks were replaced by locks that allowed limited opening, Based on observation, record review, and interview, the facility failed to provide supervision to prevent elopement for 1 (#1) of 3 sampled residents reviewed for supervision. The administrator…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-03-18 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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 maintain an abuse free environment for 3 (#2, 3, and #4) of 5 sampled residents reviewed for abuse. The administrator identified 38 residents resided in the facility. Findings:A facility policy titled Abuse, Neglect and Exploitation, implemented 01/2026, read in part, The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse.1. A quarterly assessment for Resident #2, dated 01/09/26, showed the resident had a BIMS score of 3, which indicated the resident was severely impaired in cognition, and utilized a manual wheelchair for mobility.A nurse's progress note for Resident #2, dated 02/20/26, showed CNA #1 reported Resident #2 was on the floor in a resident's room. The progress note showed CNA #1 observed Resident…

    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 · D2026-03-18 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 a background check for 1 (PCW #1) of 1 personal care worker contracted by a family to care for an individual resident. The DON identified one resident whose family contracted a private sitter.Findings:A facility policy titled Abuse, Neglect and Exploitation, implemented 01/2026, read in part, Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.On 03/18/26 at 10:20 a.m., PCW #1 stated they were a home health aide contracted with the family of Resident #5 to provide care and company to Resident #5. PCW #1 stated they worked with Resident #5 for several years and continued to work with them when they moved to the facility in September of 2025. On 03/18/26 at 11:00 a.m., the DON stated they were not aware the facility needed to perform a background check on someone contracted by the family to provide care to a particular resident and doubted the facility had performed 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to report injuries of unknown origin to required agencies for one (#1) of three sampled residents who were reviewed for injuries of unknown origin. The DON identified 47 residents resided at the facility. Findings: Resident #1 had diagnoses which included vascular dementia, anxiety, and frequent falls. A review of incident reports for Resident #1 revealed two incident reports for injuries of unknown origin on 10/26/24 and 12/10/24. Both were bruising, first to the temple and then to the right upper thigh. Review of state reports revealed the injury of unknown origin, dated 01/16/25, for a right subcaptial femoral neck fracture (a fracture that occurs in the neck of the femur, specifically at the junction where the femoral head meets the neck), was reported to OSDH on 01/17/25. No state reports were located for the 10/26/24 and 12/10/24 injuries of unknown origin. On 01/29/25 at 3:00 p.m., CNA #1 stated they reported falls, wounds, skin tears, pain, soreness, and red and purple bruises to the nurse. On 01/29/25 at 3:05 p.m.,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-31 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation, record review, and interview, the facility failed to ensure residents were treated with dignity by being called their preferred name for three (#18, 20, and #24) and failed to ensure dignity with dining for nine (#5, 10, 12, 15, 18, 26, 33, 34, and #44) of eight sampled residents who were reviewed for dignity. The DON identified eight residents who were dependent on staff for meals who ate in the dining room. Findings: An undated Promoting/Maintaining Resident Dignity During Mealtimes policy, read in part, .All staff will be seated, if possible, while feeding a resident . 1. On 10/28/24 at 8:21 a.m., the DON was observed to assist dependent residents with the morning meal in the dining room. The DON was observed to stand while assisting Resident #44, 33, and Resident #5. On 10/28/24 at 12:12 p.m., the DON was observed to assist dependent residents with the noon meal in the dining room. The DON was observed to stand while assisting Resident #18, 15, 26 and Resident #10. On 10/28/24 at 12:18…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents were transferred safely with a mechanical lift for two (#21 and #18) of two sampled residents reviewed for mechanical transfers. The DON identified four residents who utilized a mechanical lift. Findings: 1. Resident #21 had diagnoses which included dementia, anxiety, and heart failure. A care plan for Resident #21, initiated 02/28/24, documented to transfer with two staff using the mechanical lift. On 10/28/24 8:04 a.m., CNA #2 entered the room of Resident #21 alone with the mechanical lift. On 10/28/24 at 8:29 a.m., CNA #2 opened the door to the room of Resident #21. The mechanical lift was observed in the room and the resident was observed to be in their wheel chair with the sling under them. On 10/30/24 at 1:37 p.m., CNA #2 stated Resident #21 was transferred using the mechanical lift. CNA #2 stated they did not transfer Resident #21 using two staff because the resident told them to go ahead and get him up without two staff. 2. Resident #18 had diagnoses which included Alzheimer's and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-31 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure insulin was dated when opened for one (treatment cart #1) of two medication carts observed for medication storage. The DON identified four medication carts in the facility and five residents who were ordered insulin. Findings: An undated Labeling of Medications and Biologicals policy, read in part, .Labels for multi-use vials must include .The date the vial was initially opened or accessed . An undated Insulin Pen policy, read in part, .Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation . On 10/30/24 at 9:58 a.m., treatment cart #1 was observed with LPN #1. The following medications were observed to be opened and not dated. a. Lantus insulin vial for Resident #15; b. Fiasp flex touch pen for Resident #10; c. insulin aspart pen for Resident #27; d. insulin aspart pen and Basaglar pen for Resident #42; e. Levemir pen and insulin aspart for Resident #1; and f. glucose check strips. On 10/30/24 at 10:02 a.m., LPN #1 stated they did not know what date the above…

    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 · E2024-10-31 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 documentation was maintained that staff were educated and offered the COVID-19 vaccine for two of two employees reviewed for the COVID-19 vaccination. The COVID-19 Vaccination policy, dated 06/27/23, read in part, .The facility will maintain documentation related to staff COVID-19 vaccination and includes at a minimum: a. Education to the staff regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. The offering of the COVID-19 vaccine or information on obtaining the COVID-19 vaccine; c. The COVID-19 vaccine status of staff . On 10/31/24 at 3:03 p.m., the infection preventionist stated they did not have any documentation related to staff education of the COVID-19 vaccination for CNA #2. On 10/31/24 at 3:55 p.m., the administrator stated they did not have documentation for CNA #4 regarding staff education of the COVID-19 vaccination. On 10/31/24 at 4:08 p.m., the administrator stated they discussed the COVID-19 vaccination with new employees during orientation, but they did not maintain…

    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 · D2024-10-31 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure assessments were accurate for one (#9) of one sampled residents reviewed for accuracy of assessments. The administrator identified 48 residents who resided in the facility. Findings: Resident #9 had diagnoses which included dementia. The admission assessment, dated 08/11/24, documented the resident was on an anticoagulant medication and was not on an antiplatelet medication. Review of the physician orders revealed the resident was on Plavix (an antiplatelet medication), but there was no documentation an anticoagulant medication had been ordered. On 10/30/24 at 11:31 a.m., the MDS coordinator stated the resident was on Plavix and they had coded the medication as an anticoagulant instead of an antiplatelet medication. On 10/30/24 at 12:59 p.m., the DON stated the corporate office reviewed the assessments for accuracy.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents were monitored during nebulizer treatments for one (#20) of one sampled residents reviewed for respiratory care. The DON identified one resident who had orders for nebulizer treatments. An undated Nebulizer Therapy policy, read in part, .Observe resident during the procedure for any change in condition . Resident #20 had diagnoses which included chronic obstructive pulmonary disease. A physician order, dated 10/06/24, documented the resident was ordered ipratropium-albuterol (broncodilator) 0.5-2.5 (3mg/3ml) inhale every six hours. On 10/28/24 at 8:47 a.m., CNA #2 was observed to turn off the nebulizer machine and remove the nebulizer mask from Resident #20. On 10/29/24 at 11:42 a.m., LPN #1 was observed to prepare and administer ipratropium-albuterol via nebulizer to Resident #20. LPN #1 stated, Sometimes [they] keep it on, sometimes [they] won't when they placed the nebulizer mask on the resident. On 10/29/24 at 11:48 a.m., LPN #1 left the resident's room with the nebulizer mask in place.…

    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 before2024-10-31 · 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 a resident was accurately assessed for the safe use of bed rails for one (#98) of three sampled residents reviewed for bed rails. The DON identified four residents who had bed rails applied to their beds. Findings: An undated facility Proper Use of Bed Rails policy, read in part, Appropriate alternative approaches are attempted prior to installing or using bed rails .If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails . Resident #98 had diagnoses which included, Alzheimer's disease, dementia, and repeated falls. A review of falls for Resident #98 revealed a witnessed fall on 10/09/24, a witnessed fall on 10/16/24, an un-witnessed fall on 10/17/24, and an un-witnessed fall on 10/30/24 in their room during the hours of sleep. A Fall Risk Assessment, dated 10/23/24, documented Resident #98 was a high fall risk. A care plan, initiated 10/28/24, documented bed rails (two half rails), were added to Resident #98's bed for sacral wound, comfort, and mobility. 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
Show the remaining 20 citations
  • Potential for harm · Dcited before2024-10-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure infection control was maintained during dining for two (morning and noon meal) of two meals observed. The DON identified eight residents who were dependent on staff for meals. On 10/28/24 at 8:27 a.m., the DON was observed to assist four residents with the morning meal. The DON was observed to pick up a biscuit with jelly with their bare hands and place it to a resident's mouth without sanitizing their hands. On 10/28/24 at 12:12 p.m., the ADON was observed to assist four residents with the noon meal. The ADON was observed to assist a resident with a drink by touching the straw then continue to assist other residents with their meal without sanitizing their hands. On 10/28/24 at 12:18 p.m., the DON was observed to pick up a dinner roll and hand it to a resident they were assisting without sanitizing their hands. On 10/30/24 at 1:51 p.m., the DON stated staff should not directly touch residents' food or straws with their bare hands.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · 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, interview, and record review, the facility failed to ensure ongoing monitoring and supervision of bed rails for one (#98) of one resident sampled for bed rails. The DON identified four residents who had bed rails. Findings: An undated facility Proper Use of Bed Rails policy, read in part, Appropriate alternative approaches are attempted prior to installing or using bed rails .If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails . Resident #98 had diagnoses which included, Alzheimer's disease, dementia, and repeated falls. On 10/31/24 at 12:16 p.m., the DON was asked what kind of assessment was done after the bed rails were applied. They stated a bed rail assessment was completed by the ADON. On 10/31/24 at 12:28 p.m., the director of maintenance stated they installed the bed rails, but they did not perform continued safety checks. They stated they just checked them if they were informed the bed rails were loose, and then tightened the bed rails. On 10/31/24 at 12:37 p.m., the bed rail on the resident's bed 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-16 · tag F0568 — pattern
    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

    Based on record review and interview, the facility failed to provide financial quarterly statements for four (#2, 3, 4, and #5) of four sampled residents who had monies deposited in the facility's resident trust. The trust account balance statement, dated 10/15/24, documented 10 residents with funds deposited in the facility trust. Findings: 1. Resident #2 had diagnoses with included dementia and was listed on the trust account balance statement as having funds deposited in the facility's resident trust. 2. Resident #3 had diagnoses with included dementia and was listed on the trust account balance statement as having funds deposited in the facility's resident trust. 3. Resident #4 had diagnoses with included dementia and was listed on the trust account balance statement as having funds deposited in the facility's resident trust. 4. Resident #5 had diagnoses with included dementia and was listed on the trust account balance statement as having funds deposited in the facility's resident trust. On 10/16/24 at 3:45 p.m., the BOM stated they were somewhat new to their position and had…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-16 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 provide toenail care for one (#1) of five sampled residents whose clinical records were reviewed for foot care. The facility's resident list report, dated 10/14/24, documented 46 residents. Findings: Resident #1 admitted to the facility on [DATE] with diagnoses which included gout. The admitting orders, dated 08/16/24, documented the resident was to receive podiatry care as needed. The shower sheet, dated 08/18/24, documented the resident's toenails needed to be cut. The shower sheet, dated 08/23/24, documented the resident's toenails needed to be cut. The admission assessment, dated 08/27/24, documented the resident was mildly impaired in cognition and required assistance with bathing and hygiene. The shower sheet, dated 08/31/24, documented the resident's toenails needed to be cut. The shower sheet, dated 09/03/24, documented the resident's toenails needed to be cut. On 10/15/24 at 4:00 p.m., CMA #1 stated the resident's toe nails were long, thick,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-22 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to provide a NOMNC and ABN notice for two (#23 and #15) of three sampled residents reviewed for Beneficiary Notices. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility. Findings: An Advance Beneficiary Notices policy, undated, read in part, .It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage . On 09/20/23 the Administrator provided a copy of the Entrance Conference Worksheet that documented Resident #23 was discharged on 03/31/23 and remained in the facility and Resident #15 was discharged on 03/31/23 and remained in the facility. On 09/20/23 at 12:30 p.m., the Administrator was asked if the beneficiary notices had been provided to Resident #23 and Resident #15. They stated all they had was documentation with the two Residents (#23 and #15) names at the top but they had not been signed. The Administrator was asked if Resident #23 and #15 had been provided the required notices. They stated, No.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-22 · tag F0637 — pattern
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to complete a significant change assessment for two (#2 and #5) of four sampled residents reviewed for a significant change of status. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility. Findings: An MDS 3.0 Completion policy, undated, read in part, .Residents are assessed, using a comprehensive assessment process , in order to identify care needs and to develop an interdisciplinary care plan .A significant change is a major decline or improvement in a resident's status that .will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions .impacts more than one area of a residents health status, and .requires interdisciplinary review and/or revision of the care plan 1. Resident #2 had diagnoses which included Alzheimer's disease, high blood pressure, atrial fibrillation and anxiety. A significant change in status assessment, dated 05/08/23, documented Resident #2 needed limited assistance of one staff 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to complete smoking risk assessments to ensure the continued safety during smoking for one (#22) of one sampled resident reviewed for smoking. The Resident Census and Conditions of Residents report, dated 09/19/23, documented 38 residents resided in the facility. Findings: A Resident Smoking policy, dated 02/10/22, read in parts, .Safety measures for the designated smoking area will include .Provision of Smoking Apron .All residents will be asked about tobacco use during admission process, and during each quarterly or comprehensive MDS assessment process .Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment .whether or not supervision is required .resident is safe to smoke at all . Resident #22 had diagnoses to include dementia and nicotine dependence. A Physician Order, dated 04/30/22, documented Resident #22 was to have a smoking assessment completed before the resident smoked for the first time. Resident #22 would have a limit of two cigarettes, three times a day, with no…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-22 · 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

    Based on record review and interview, the facility failed to ensure side effects were monitored for the use of anxiety medications for one (#2) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions report, dated 09/19/23, documented 17 residents received anxiety medications and 38 residents resided in the facility. Findings: A Unnecessary Drugs-Without Adequate Indication for Use policy, dated 02/22/22, read in part, .It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs . Resident #2 had diagnoses which included Alzheimer's disease, high blood pressure, atrial fibrillation and anxiety. A Physician Order, dated 05/24/23, documented to administer Klonopin 0.5 mg, one tablet three times a day. Resident #2's June, July and August 2023 TAR's did not contain documentation Resident #2 had been monitored for side effects related to the use of Klonopin. On 09/21/23 at 1:12 p.m., RN #1…

    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 · E2023-09-22 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to obtain lab (Hemoglobin A1c) for one (#15) of one sampled resident reviewed for laboratory services. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility. Findings: An undated, Laboratory Services and Reporting policy, read in part, .The facility must provide or obtain laboratory services to meet the needs of its residents .The facility is responsible for the timeliness of the services . Resident #15 had diagnoses which included type two diabetes mellitus, dementia, and high blood pressure. A Physician Order, dated 05/09/23, documented to draw a Hemoglobin A1c, every month for three months. The clinical health record did not contain documentation Resident #15's Hgb A1c lab had been obtained for the three months as ordered. On 09/21/23 at 9:18 a.m., the ADON was asked if the Hgb A1c had been completed as ordered. They stated no, the last one had been done in February 2023.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-22 · 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, record review, and interview, the facility failed to maintain the kitchen to promote food safety and sanitation. The Resident Census and Condition of Residents report, dated 09/19/23, documented 38 residents resided in the facility. Findings: An undated End of Shift Cleaning Check List, read in parts, .Sweep and mop kitchen, walk in cooler and dry store area including under all equipment . On 09/19/23 at 12:11 p.m., an initial tour of the kitchen was conducted. The serving of the noon meal was in progress the following were observed: a. The floor of the kitchen and pantry had dirt and debris with a build-up under the equipment and along the edges of the floors. b. A June - 23 Dish Washer Temperature/Chemical Record report, documented the dish machine was last monitored for the hot water and chemical levels on 06/14/23. On 09/19/23 at 12:30 p.m., CDM #2 was asked when the dish machine was last checked for water temperatures and chemicals. They stated, it should have been this morning. CDM #2 to review the form, dated June 2023, with the last entry on the 14th…

    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 · E2023-09-22 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure trash cans in the kitchen were covered. The Resident Census and Condition of Residents report, dated 09/19/23, documented 38 residents resided in the facility. Findings: An undated End of Shift Cleaning Check List, read in parts, .Trash Cans emptied and cleaned .Put lid on trash can before serving and before leaving . On 09/19/23 at 12:11 p.m., an initial tour of the kitchen was conducted. The serving of the noon meal was in progress. The trash can located near the hand washing sink overflowed with used paper towels. There was not a lid on or near the trash can. On 09/21/23 at 11:30 a revisit to the kitchen was conducted. The preparation of the noon meal was in progress. The trash can located near the hand washing sink overflowed with used paper towels. There was not a lid on or near the trash can. On 09/21/23 at 12:40 p.m., CDM #1 was asked if there was a reason the trash can near the hand sink did not have a lid. They stated, I did not think we needed one since it was not near the food prep area and only contained…

    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 · E2023-09-22 · tag F0851 — pattern
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to submit accurate data for 24 hour licensed skilled nursing to CMS for three of three months reviewed. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility. Findings: A PBJ Staffing Data Report, dated 04/01/23 though 06/30/23, documented there was no licensed nursing coverage 24 hours a day for 04/29/23, 05/10/23, 06/20/23, 06/24/23, and 06/25/23. On 09/22/23 at 2:01 p.m., the Administrator was asked for documentation that there was 24 hour licensed coverage for 04/29/23, 05/10/23, 06/20/23, 06/24/23 and 06/25/23. The Administrator was asked who reports the quality of care staffing reports. They stated the corporate office. They were asked if agency staff had been reported. They stated No. The Administrator was unsure of the dates in April and May as they had started their position in June 2023. On 09/22/23 at 2:54 p.m., the Administrator was asked if the staffing data had been reported correctly. They stated June was not reported accurately, I didn't report agency staff,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-22 · 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 staff sanitized a blood pressure cuff between two (#24 and #17) of five sampled residents reviewed during medication observation. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility. Findings: A Standard Precautions Infection Control [name of facility] policy, dated 11/10/21, read in part, All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services . On 09/22/23 at 7:40 a.m. upon arrival to the medication cart, CMA #1 was observed to be wearing a b/p wrist cuff around their left wrist. On 09/22/23 at 7:46 a.m., CMA #1 was observed to obtain a b/p using the wrist cuff on Resident #24. CMA #1 then was observed to return to the cart and place the b/p cuff on top of the cart. They were not observed to sanitize the b/p cuff. On 09/22/23 at 8:04 a.m., CMA was observed to remove the cuff from the top of the cart and obtain a blood pressure…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 privacy during the provision of toileting for one (#27) of three sampled residents reviewed for ADL care. The Resident Census and Conditions of Residents report, dated 09/19/23, documented 38 residents resided in the facility. Findings Resident #27 had diagnoses to include Alzheimer's disease, and seizures. A Quarterly Assessment, dated 07/26/23, documented Resident #27 had clear speech, usually understood, usually understands, and required extensive assistance for transfers, walking, and toileting. A Care Plan, dated 04/22/22, was provided by the facility and did not address ADLs or the extent of assistance required by staff. On 09/22/23 at 1:45 p.m. Resident #27 was observed to be in full view from the hallway, to be seated on the toilet, undressed from the waist down. A staff member was seated on a shower chair in front of the resident. The room door was slightly opened, and the bathroom door was completely opened. When the surveyor approached the opened doors, CNA #4 made eye contact and rapidly…

    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 · D2023-09-22 · 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 provide a written notice of transfer for one (#38) of one resident reviewed for hospitalization. The Resident Census and Conditions of Residents report, dated 09/19/23, documented 38 residents resided in the facility. Findings: Resident #38 had diagnoses to include dementia and anxiety. A Progress Note, dated 09/08/23, documented Resident #38 had been transferred to a local hospital. The clinical record contained no documentation the resident or representative had been provided written information regarding the discharge at the time of discharge to the hospital. On 09/21/23 at 10:37 a.m., the ADON was asked what paper work was provided to the resident or representative at the time of discharge to the hospital. They stated, We call and notify [the family]. On 09/21/23 at 10:40 a.m., the Administrator was asked what written notification of the hospital discharge was provided to the resident, resident representative, or Ombudsman when Resident #38 had…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 copy of the bed hold policy was provided for one (#38) of one resident reviewed for a discharge to the hospital. The Resident Census and Condition of Residents report, documented 38 residents resided in the facility. Findings: Resident #38 had diagnoses to include dementia and anxiety. A Progress Note, dated 09/08/23, documented Resident #38 had been discharge to a local hospital. The clinical record did not contain documentation the resident or representative had been provided written documentation of the bed hold policy at the time of discharge. On 09/21/23 at 10:37 a.m., the ADON was asked what paper work was provided to a resident that is discharged to the hospital. They stated the charge nurse prints a face sheet, DNR or advance directive, the current orders, a medication administration list, and if going to a psychiatric hospital, progress notes are sent. The ADON was asked if the resident or representative are provided a copy of a bed hold policy. They stated that would come from the office and not sure…

    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 · D2023-09-22 · 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 daily staffing information in a prominent place which was readily accessible to residents and visitors. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility. Findings: On 09/22/23 at 3:40 p.m., RN #1 was asked where the daily nurse staffing was posted. They stated it was on hall 100. The wall on Hall 100 was observed with RN #1. There was no white board on the wall. On 09/22/23 at 3:44 p.m., RN #1 asked the Administrator where the board was. The Administrator stated they were unsure what happened to the board.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-20 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure Do Not Resuscitate (DNR) forms were complete for one (#10) and ensure the code status was accurate for one (#73) of two sampled residents who were reviewed for advanced directives. The facility identified twelve residents who had a DNR on file. Findings: 1. Resident #73 had diagnoses which included dementia and Down syndrome. A physician order, dated 09/09/22, documented the resident was a DNR. A care plan, dated 10/05/22, read in part, .I am a full code . Review of the electronic clinical record did not reveal a DNR on file. The electronic face sheet documented the resident was a DNR. On 10/21/22 at 2:10 p.m., the BOM was asked what their role was regarding advanced directives. They stated they reviewed with resident/resident representatives code status and advanced directives upon admission to the facility. The BOM was asked how staff were made aware of the code status of the residents. They stated they could check the electronic clinical record or the paper chart. They were asked what the code status was 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-20 · tag F0700 — pattern
    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 attempt alternatives, assess for risks, and obtain informed consent for the use of bedrails for two (#72 and #121) of two residents reviewed for bed rails. The DON identified two residents with bed rails. Findings: A Proper Use of Bedrails policy, dated 01/10/22, read in parts, .The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The resident assessment must also assess the resident's risk from using bed rails .Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails .Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail . 1. Resident #72 had diagnoses which included Non-Alzheimer's Dementia. The admission assessment, dated 09/22/22, documented the resident was dependent on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-20 · 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 observation, record review, and interview, the facility failed to ensure medication was available for one (#74) of ten residents who were observed during medication pass. The DON identified 26 residents who received medications. Findings: A physician order, dated 09/20/22, documented the resident was to receive Metformin (a medication for diabetes) 500mg by mouth twice a day. A physician order, dated 09/20/22, documented the resident was to receive Latanoprost (a medication for glaucoma) eye drops 0.005% one drop in both eyes at bedtime. The Medication Administration Record, dated 10/01/22 through 10/31/22, revealed the resident had not received the Latanoprost on 10/06/22, 10/07/22, 10/10/22, or 10/18/22. The MAR revealed the resident had not received the Metformin on 10/19/22 in the morning or evening and had not received the morning dose of Metformin on 10/20/22. The Progress Notes, dated 10/01/22 through 10/20/22, documented the Latanoprost was not available on the above listed dates and the Metformin was on order on the above listed dates. On 10/20/22 at 8:56 a.m., CMA…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,653 in federal fines across 1 penalty.

  • $8,653 — penalty dated 2025-01-29

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

Who owns this facility

Owner / managerTypeRoleSince
RIVERS EDGE OPERATIONS III LLCOrganizationDIRECT OWNERSHIP INTERESTsince 06/01/2025
RIVERS EDGE PARTNERS II LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
HANOVER, YAACOVIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 06/01/2025
KRAVETZ, AVROHOMIndividualINDIRECT OWNERSHIP INTERESTsince 06/01/2025
OMCI REALTY LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 06/01/2025
GANZ, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
RETTER, S. ARYEHIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
SKYBLUE HEALTHCARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/26/2026
MOORE, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
RIFE, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
RIVERS EDGE PROPERTY HOLDINGS III LLCOrganizationADP OF THE SNFsince 06/01/2025

CMS files one row per role, so the 20 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

5 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.

$3.3M
Net patient revenuemost recent cost report
-2.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 84%Medicare 1%Other / private 15%

About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

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

$235per resident / day
operating cost
$7,131per month
≈ monthly operating cost
$229per 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 375468. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-31, 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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