Heartsworth Center For Nursing & Rehabilitation
1200 West Canadian Avenue, Vinita, OK 74301 · For profit - Limited Liability company · 146 certified beds · (918) 256-8768 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,430 in federal fines (most recent 2025-09-18)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.4% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 3.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 3.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 4.7% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.3% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.4% | 25.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.0% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.4% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.4% | 74.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.5% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.3% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.97 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.28 | 2.96 | 1.80 | worse |
* 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.
58.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 120 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 60 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.0%CMS range 48.7–65.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.1%CMS range 9.8–16.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 66.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 45.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 90.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison 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 discharge | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 4.2–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 146 beds and averages 64.2 residents a day — about 44% occupied, or roughly 82 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 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.47 hrs/resident/day on weekends vs 3.67 on weekdays — 5% thinner on weekends. RN hours go from 0.38 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
34 citations, most serious first. The 11 most serious are shown; the remaining 23 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-09-18 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On [DATE], an IJ was determined to exist related to the facility's failure to ensure a resident who had chosen to have a full code status was provided CPR after a life threating medical emergency was discovered. On [DATE] CNA #1 found Res #3 in their room and unresponsive. CNA #1 reported the situation to LPN #1 who checked the blood pressure of the resident then told CNA #1 the resident was dead and to clean them up. CNA #1 stated no code had been called for Res #3 and no CPR had been attempted.On [DATE] at 12:02 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On [DATE] at 12:20 p.m., the DON was notified of the IJ situation and provided the IJ template.On [DATE] at 4:09 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health.The facility plan of removal, dated [DATE] at 4:09 p.m., read in part, On [DATE], the facility QAPI members met to discuss this event, root cause, immediate implementation of interventions 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.
- Potential for harm · Fcited before2025-09-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 equipment in the kitchen was sanitized. The ADON reported 70 residents received meals from the kitchen. Findings:On 09/15/25 at 11:50 a.m., cook #1 was observed recording temperatures of food being held on the steam table. [NAME] #1 was observed to place the thermometer into a container of Brussel sprouts, remove the thermometer from the Brussel sprouts, grab a towel off the counter and wipe off the thermometer. [NAME] #1 then placed the thermometer into the sweet potatoes, removed the thermometer from the container of sweet potatoes and wiped the thermometer off with the same towel. [NAME] #1 then placed the thermometer into a container of sliced ham, removed the thermometer from the container or ham, and wiped it off using the same towel.A facility policy titled Sanitization, revised 11/2022, read in part, The food service area is maintained in a clean and sanitary manner.All equipment, food contact surfaces, and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.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.
- Potential for harm · D2025-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to ensure that oxygen cylinders were stored securely. The ADON reported 19 residents utilized supplementary oxygen. Findings:On 09/15/25 at 1:00 p.m., an oxygen cylinder was observed in Res #9's room. The cylinder was upright and unsecured next to the head of Res #9's bed.An undated facility policy titled Oxygen Safety, read in part, When small-sized (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to medical equipment designed to receive and hold compressed gas cylinders. On 09/16/25 at 12:20 p.m., CNA #3 stated oxygen cylinders should be attached to the resident's wheelchair or in some type of oxygen tank holder.On 09/16/25 at 12:30 p.m., LPN #2 stated oxygen cylinders should not be unsecured in a resident's room.On 09/16/25 at 1:50 p.m., the ADON stated oxygen cylinders should be stored securely in a carrier.
- Potential for harm · Ecited before2024-05-02 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to include a focus of wandering in a comprehensive care plan for one (#4) of two residents reviewed for wandering. The ADON identified two residents in the facility that wandered. Findings: A facility Elopements and Wandering Resident policy, dated 01/01/20, read in part, The facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with with their person-centered plan of care addressing the unique factors contributing to wandering or elopement. Resident #34 had diagnoses which included recurrent depressive disorder. A progress note, dated 01/26/24 at 8:08 a.m., documented the Resident #34 had been wandering and continued attempting to enter other residents' rooms. A progress note, dated 01/26/24 at 10:02 a.m., documented the Resident #34 was found in their room with the shoes of a male resident. A progress note, dated 01/26/24 at 5:12 p.m., documented the Resident #34 had attempted to enter the kitchen while…
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.
- Potential for harm · E2024-05-02 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to serve foods at a palatable temperature from one of two kitchen service areas. The DON identified 40 residents who ate meals served from the satellite kitchen. Findings: The facility policy titled Food and Nutrition Services, read it part, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. On 05/01/24 at 11:15 a.m., the satellite kitchen was observed. The mid-morning meal, including breakfast and lunch style options were observed on the steam table. The steam table was not producing steam. The back and sides of the steam table felt only warm to the touch. The holding temperature of the sausage patties was 94 degrees Fahrenheit. The holding temperature of the soup from 118 degrees Fahrenheit. On 05/01/24 at 11:16 a.m., [NAME] #1 stated they were not sure what the holding temperature was for hot foods. The cook stated the steam table was turned 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.
- Potential for harm · E2024-05-02 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 three substantive meals were served daily. The ADON reported 73 residents received meals from the kitchen. Findings: An undated facility policy titled Frequency of Meals, read in part, .Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and the plan of care . A handwritten document provided by the DM documented that east hall had breakfast served at 7:30 am, the snack cart went out at 7:30 am, brunch was served at 10:30 am, the snack cart went out again around 1:30 pm, supper was served at 4:30 pm, and the snack cart went out again at 6:30 pm. On 04/29/24 at 8:32 am, the DM stated that a breakfast snack was served in the morning and then brunch which has breakfast items was served. They also stated a midday snack was served then an evening meal was served around 4:30 pm followed by an evening snack. On 05/02/24 at 9:10 am, the DM stated that a hot breakfast was served on the skilled unit,…
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.
- Potential for harm · Ecited before2024-05-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain the physical environment of the main kitchen and failed to serve cold foods in the satellite dining room in a sanitary manner. The DON identified 79 residents who ate meals prepared in the main kitchen. Findings: On 04/29/24 at 8:32 a.m., the kitchen was observed to not have a dedicated handwashing sink. On 04/29/23 at 8:32 a.m., the dietary manager stated the staff used the two compartment sink to wash their hands. The dietary manager stated the two compartment sink was used to fill pots with with water and other food preparation needs. On 04/29/24 at 8:33 a.m., the kitchen was observed to have: - missing and broken baseboards, - holes in the ceiling, - rusted air vents and lighting fixtures in the ceiling, - multiple yellow and orange water stains on the ceiling, - peeling paint located on the ceiling and above the food preparation areas, - no dedicated hand washing sinks in the main or satellite kitchens, - an unsecured bottom grill hanging from under the left door of the two door refrigerator, and - and two…
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.
- Potential for harm · E2024-05-02 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 residents binding arbitration agreements that: a. informed the resident or their representative of their right not to sign the agreement as a condition of admission or continued care; and b. does contains an explicit acknowledged by the resident or their representative that they understood the provisions of the agreement; and c. does not include the name of a second nursing facility, in which the resident does not reside or is aware of, in the agreement for two (#50 and #63) of two sampled resident reviewed for arbitration agreements. The facility SSD stated 60 residents that resided in the facility had signed binding arbitration agreement. Findings: A facility Binding Arbitration Agreements policy, dated 07/18/19, read in part, This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this…
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.
- Potential for harm · D2024-05-02 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 assist a resident with their meal in a dignified manner for one (#10) of eight residents observed for dining. The DON identified three residents who required total assistance with meals. Findings: The facility's Assistance with Meals policy, documented that residents who could not feed themselves would be fed with attention to dignity. As examples, the policy documented not to stand over residents while assisting them with their meals and to keep interactions with other staff to a minimum while assisting residents with their meals. On 04/29/24 at 10:53 a.m., Resident #10 was reclined in a geri-chair, in the dining room. Facility staff stood beside the resident and assisted the resident with their meal. The staff member was heard to talk with various other staff members as they stood beside Resident #10. On 05/01/24 at 11:20 a.m., Resident #10 was reclined in a geri-chair, in the dining room. CNA #4 stood beside the resident and assisted the resident with their meal. The staff member was heard to talk with…
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.
- Potential for harm · D2024-05-02 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 provide education about advance directives and provide an opportunity for a resident to have or decline an advance directive for one (#63) of 24 sampled residents reviewed for advance directives. A facility daily census report, dated 04/29/24, documented 73 residents resided at the facility. Findings: A review of Resident #63's EMR found any documentation of an advance directive. The EMR did contain an order for full code but no paperwork that it was discussed with the resident or a representative was found in the records. On 05/01/24 at 7:25 a.m., the ADON stated they had reviewed Resident #63's records and did not find documentation of an advance directive. They stated they did find a physician's order for full code status but not the paperwork that code status was discussed with the resident or a representative. On 05/01/24 at 7:59 a.m., the ADON stated the resident did not have an advance directive and there was no documentation in their records they were given education on advance directives or given the opportunity…
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.
- Potential for harm · D2024-05-02 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide privacy for one (#44) of one resident observed to have a facility camera in their room. The DON identified there were two residents for which the facility had placed a camera in the residents' rooms. Findings: The comprehensive assessment, dated 01/20/24, documented the resident was severely impaired in cognition, experienced an acute change in mental status, and exhibited no behaviors such as wandering or rejection of care. The quarterly assessment, dated 04/10/24, documented the resident was severely impaired in cognition, experienced an acute change in mental status, and exhibited no behaviors such as wandering or rejection of care. On 04/29/24 at 09:30 a.m., Resident #44 was interviewed in their room while they were in bed. There was a camera positioned on the opposite wall from the resident's headboard and faced toward the bed. Resident #44 stated they had difficulty hearing. The resident responded to open ended questions, including questions regarding the use of a camera in their room, with inappropriate…
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.
Show the remaining 23 citations
- Potential for harm · D2024-05-02 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the accuracy of a baseline care plan for one (#219) of two residents sampled for baseline care plan. The administrator reported the census was 73. Findings: An undated facility policy titled Care Plans-Baseline read in part, .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident . Resident #219 had diagnoses which included hypertension and anemia. A baseline care plan, dated 04/17/24, documented the resident had a pressure ulcer upon admission. An admission skin assessment, dated 04/17/24, documented the resident had normal skin with good elasticity and no new wounds. On 05/01/24 at 1:20 p.m., the ADON stated she was unaware the resident had any skin issues at admit. On 05/02/24 at 9:42 a.m., MDS coordinator #2 stated she was responsible for Resident #219's baseline care plan and the information regarding the 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.
- Potential for harm · D2024-05-02 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the consulting pharmacist documented the correct dosage of a psychotropic medication on a request for dosage reduction for one (#11) of five residents whose clinical records were reviewed for unnecessary medications. The ADON identified 16 residents who received psychotropic medications. Findings: The physician's order, dated 05/11/23, documented the resident was to receive Zoloft 200 mg daily. The request for a gradual dose reduction, dated 06/17/23, documented the resident received Zoloft 100 mg daily. The physician's order, dated 06/26/23 was written on the pharmacist's request for gradual dose reduction and documented to decrease Zoloft to 50 mg daily. The physician's order, dated 07/13/23, documented the resident was to receive Zoloft 200 mg daily. On 05/02/24 at 9:42 a.m., the ADON stated the pharmacist documented an incorrect dosage on the request for gradual dose reduction and the physician may have based their decision to reduce 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.
- Potential for harm · D2024-05-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 notify the physician of a wound for one (# 219) of one resident sampled for wounds. The ADON identified seven residents in the facility with wounds. Findings: An undated facility policy titled Change in a Resident's Condition or Status read in part, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the residents' medical/mental condition and/or status .The nurse will notify the residents' attending physician or physician on call when there has been a . need to alter the residents' medical treatment significantly . Resident #219 had diagnoses which included hypertension and anemia. An admission skin assessment, dated 04/17/24, documented the resident had normal skin with good elasticity and no new wounds. A nurse note, dated 04/28/24 at 5:42 pm, documented the resident had an open sore on their right buttocks. A review of Resident #219's medical record did not document the physician had been notified regarding the open area. On 05/01/24…
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.
- Potential for harm · Dcited before2024-05-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 and interview, the facility failed to prevent a medication room door from being propped open by a chair and the medication room being open and unattended by appropriate staff. A facility daily census report, dated 04/29/24, documented 73 residents resided at the facility. Findings: The facility's Medication Labeling and Storage policy, dated 02/2023, read in part, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 04/30/24 at 6:51 a.m., the facility medication room door was found propped open with a chair and the medication room unattended. There were no staff members observed inside the room or in the hallways next to the room who may have been observing the room. Four locked medication carts were located in the medication room. Various types of resident medications were found in bins located on shelves 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.
- Potential for harm · D2024-05-02 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the lint screens were cleared as recommended for three of three dryers observed in the laundry room. The administrator reported the facility census was 73. Findings: On 04/30/24 at 10:25 am, Laundry Employee #1 reported the sign on the dryer indicated the lint screen should be cleaned every 4 hours, but when they were busy, they only cleaned it every eight hours or so. On 04/30/24 at 10:25 am, signs were observed to be affixed to all three dryers in the laundry room, these signs stated the lint screens were to be cleaned every 4 hours. On 04/30/24 at 10:30 am Laundry Employee #1 was asked to remove the cover to expose the lint screen on one of the dryers. Once the cover was removed a considerable amount of lint was observed to be covering the screen. The employee stated they had not cleaned the lint screens today, but they assumed the screens had been cleaned yesterday. On 05/02/24 at 1:50 pm, the maintenance supervisor stated that laundry employees were responsible for cleaning the lint screen and maintenance 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.
- Potential for harm · Dcited before2023-12-05 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 prevent a nurse aide whose CPR certification did not include hands-on training and an in person skilled assessment, from providing chest compressions to a resident who was deemed by staff to require cardiopulmonary resuscitation for one (#1) of one sampled resident reviewed for quality of care. A midnight census report, dated [DATE], documented 72 residents resided in the facility. Findings: Resident #1 had diagnoses which included Cardiomyopathy, chronic congestive heart failure, atherosclerotic heart disease, and morbid obesity. A Emergency Procedure - Cardiopulmonary Resuscitation policy, revised date February 2018, read in part, .Preparation for Cardiopulmonary Resuscitation 1. Obtain and/or maintain [organization names withheld] certification in Basic Life Support (BLS/Cardiopulmonary Resuscitation (CPR) . A certificate of completion for CPR, dated [DATE], documented CNA #1's training was the online only version. A progress note, created date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-30 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure residents were free from physical restraints for one (#7) of three residents reviewed for physical restraints. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: Res #7 had diagnoses which included arthritis. An annual MDS, dated [DATE], documented Res #7 was moderately cognitively impaired, was independent with ADLs, and used a rollator walker for mobility. On 03/27/23 at 11:21 a.m., Res #7 was observed in bed with the bed pushed against the wall. A bed rail was raised on both sides of the head of the bed, and a single rail was raised in the middle of the bed on the side facing the middle of the room. Res #7 stated regarding the bed rails, I just climb over them. On 03/28/23 at 1:07 p.m., Res #7 was observed in bed with a bed rail raised at the head of the bed and middle of the bed facing the middle of the room. On 03/28/23 at 1:34 p.m., RA #2 stated she was unsure why…
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.
- Potential for harm · Ecited before2023-03-30 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to review and revise a care plan for two (#45 and #56) of 24 sampled residents whose care plans were reviewed. The Residents Census and Conditions of Residents report documented 78 residents resided in the facility. Findings: 1. Res #45 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit and unspecified glaucoma. Incident reports, dated 12/21/22, 01/25/23, 02/06/23, 02/25/23, 02/26/23, and 03/09/23 documented resident falls. The reports documented interventions were put in place. The care plan was not revised with the falls and interventions. A care plan, dated 03/09/23, documented the last revision for falls was 12/01/22. An incident report, dated 03/18/23, documented the resident had a fall and an intervention was put in place. The care plan was not revised. On 03/28/23 at 1:55 p.m., MDS #1 was asked if the resident's care plan was reviewed and revised after each fall. They reported they would have 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.
- Potential for harm · E2023-03-30 · tag F0700 — patternTry 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and obtain informed consent prior to installation of bedrails for three (#7, 35, #55) of three residents reviewed for bed rails. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: 1. Res #7 had diagnoses which included arthritis. An annual MDS, dated [DATE], documented Res #7 was moderately cognitively impaired, was independent with ADLs, and used a rollator walker for mobility. On 03/27/23 at 11:21 a.m., Res #7 was observed in bed with the bed pushed against the wall. A bedrail was raised on both sides of the head of the bed and a single rail was raised in the middle of the bed on the side facing the middle of the room. Res #7 stated regarding the bed rails, I just climb over them. On 03/28/23 at 1:07 p.m., Res #7 was observed in bed with a bed rail raised at the head of the bed and one in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-30 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure: a. GDR declinations from the physician included a rationale for one (#6) of five residents reviewed for unnecessary medications and b. GDR requests were reviewed by the physician for one (#21) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: 1. Res #6 had diagnoses which included depression and anxiety. A physician order, dated 05/09/22, documented to administer sertraline 25 mg at bedtime for depression. A physician order, dated 05/09/22, documented to administer Remeron 15 mg at bedtime for poor appetite. A pharmacist monthly review GDR request, dated 06/27/22, documented a request to reduce Res #6's Remeron and sertraline. The pharmacist review read in part, .justification for NOT reducing a Psychoactive must be DOCUMENTED either on this form or within the clinical record in order to be considered clinically contraindicated…
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.
- Potential for harm · E2023-03-30 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure medication error rate was less than 5% for two (#50, #56) of five residents observed during medication pass. A total of 26 opportunities were observed with three errors. Total error rate was (7.6%) The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: 1. A physician order for Res #50, dated 01/15/23, documented to administer loratadine 10 mg daily for allergies. On 03/30/23 at 8:38 a.m., LPN #3 was observed during medication pass. The LPN was observed administering four medications. The medications in the cup did not include the loratadine 10 mg. On 03/30/23 at 10:56 a.m., LPN #3 denied omitting the medication. On 03/30/23, at 11:03 a.m., the DON stated staff passing medications were to check the medication card with the order on the EHR before administering the medication. 2. A physician order for Res #56, dated 01/06/23, documented to administer citalopram 20 mg in the morning. A physician order, dated 03/13/23, documented to discontinue 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.
- Potential for harm · Ecited before2023-03-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure: a. the kitchen was clean and maintained in good repair, b. food was stored in a sanitary manner, c. the kitchen was free of pest, and d. food products were properly labeled/identified. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: On 03/27/23 at 10:20 a.m., a tour of the kitchen was conducted. The dishwashing area had dirty dishes piled up on the table. Dish detergent and boxes of cleaner were observed sitting on the floor. The dishwashing sink would not turn off completely and was constantly running. A leak was observed in one of the hoses under the sink and leaking on the floor. The floor was observed to have a lot of dirt and calcium build up on it. There was trash and a coffee cup observed on the floor. The white tile wall behind the sink was covered in a brown substance and there was a live spider on the wall. Several live roaches were observed on the floor and on the walls. Metal shelves containing clean dishes was observed to have trash and dirt…
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.
- Potential for harm · E2023-03-30 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly 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 and interview, the facility failed to conduct regular inspections of all bed rails as part of a regular maintenance program for three (#7, 35, #55) of three residents reviewed for bedrails. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: On 03/27/23 at 11:21 a.m., Res #7 was observed in bed with the bed pushed against the wall. A bedrail was raised on both sides of the head of the bed, and a single rail was raised in the middle of the bed on the side facing the middle of the room. Res #7 stated regarding the bed rails, I just climb over them. On 03/27/23, at 11:44 a.m., Res #55 was observed in a wheelchair in the resident's room. Res #35's bed was observed pushed against the wall, with two rails raised at the head of the bed, and one rail raised in the middle of the bed facing the resident's room. The resident stated they required assistance from staff to transfer out of the bed. On 03/27/23, at 1:10 p.m., Res #35 was observed in bed. The bed was observed to have two half rails raised at the head of…
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.
- Potential for harm · E2023-03-30 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview, it was determined the facility failed to provide a safe, clean, sanitary, homelike environment. The facility failed to ensure: a. a shower room was clean and in working order and b. the laundry was free of dirt and dust. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: On 03/29/23 at 9:45 a.m., the ADON was asked how long the south hall shower room had been broken. She reported a year or less. On 03/29/23 at 9:47 a.m., the south hall shower room was observed to have mold in the shower stall on the right, with water constantly running out of the shower head. There was mold observed on all the tiles in this shower. The maintenance supervisor reported he had been storing his stuff in this room since it is not working. The maintenance supervisor was asked how long this shower had been out of order. He reported not very long. He was asked if the water has been running this entire time. He replied, Yes. On 3/30/23 at 8:30 a.m., a tour of laundry facility with laundry staff #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.
- Potential for harm · E2023-03-30 · tag F0924 — patternPut firmly secured handrails on each side of hallways.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to equip corridors with firmly secured handrails on each side. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: On 03/29/23 at 2:33 p.m., a hand rail on the 300 hall between the shower room and room [ROOM NUMBER] was observed to be loose and easily moved up and down. A hand rail between room [ROOM NUMBER] and room [ROOM NUMBER] was loose, easily moved up and down and tilted downward on the right side. On 03/30/23 at 7:33 a.m., a handrail between 200 and 300 hall on the left side next to the exit door was observed to be loose and easily moved up and down. On 03/30/23 at 8:28 a.m., the maintenance supervisor stated he was aware of loose hand rails and had not had time to get to them yet.
- Potential for harm · E2023-03-30 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, observation, and interview, the facility failed to maintain an effective pest control program. The Resident Census and Conditions of Residents documented 78 residents resided in the facility. Findings: On 03/27/23 at 10:20 a.m., during the initial tour of the kitchen there were multiple live roaches observed in the dishwashing area of the kitchen. There were live roaches crawling on the walls and floors. There was a live roach observed under the handwashing sink crawling on the wall. On 03/28/23 at 8:45 a.m., during a second tour of the kitchen there were live roaches in the dishwashing area crawling on the walls. On 03/29/23 at 2:30 p.m., the maintenance supervisor reported they had the facility treated for pest twice a month. Record review of pest control receipts documented the kitchen was treated for pests twice a month.
- Potential for harm · D2023-03-30 · tag F0582 — isolatedGive 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 ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued SN ABN notices for two (#10 and #36) of three residents reviewed for beneficiary notices. The facility identified 28 residents who were discharged from part A skilled services with benefit days remaining in the previous six months. Findings: 1. Res #10 was admitted to part A skilled services on 01/19/23, discharged from skilled services on 03/01/23, and remained in the facility. 2. Res #36 was admitted to part A skilled services on 01/23/23, discharged from skilled services on 02/17/23, and remained in the facility. On 03/28/23, the social services director was asked to provide ABN and NOMNC notifications for Res #10 and Res #36. On 03/28/23 at 12:47 p.m., the social services director provided a NOMNC notice for Res #10 and Res #36. She stated she was unaware SN ABN CMS-10055 forms should have been provided to Res #10 and Res #36.
- Potential for harm · D2023-03-30 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer a resident with a new serious mental disorder to the state for a level II PASRR evaluation for one (#15) of two residents sampled for PASRR screening and evaluations. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: Res #15 admitted [DATE] with diagnoses which included psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia. A PASRR level I, dated 03/06/12, documented Res #15 did not have a diagnosis of serious mental illness. On 10/15/18 Res #15 received a new diagnosis of schizoaffective disorder. An annual MDS, dated [DATE], documented a diagnosis of schizophrenia. On 03/29/23 at 10:59 a.m., the SSD was asked for Res #15's level two pre admission screening and resident review. On 03/29/23 at 11:58 a.m., the SSD stated she had called the Oklahoma Health Care Authority and the resident did not have a new PASRR screening completed in 2018.
- Potential for harm · D2023-03-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop a comprehensive care plan for diuretic use for one (#21) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: Res #21 admitted [DATE] and had diagnoses which included chronic heart failure, hypertension, and peripheral vascular disease. A physician order, dated 01/26/23, documented to administer Bumex (a loop diuretic) 1 mg two times a day for congestive heart failure. A significant change MDS, dated [DATE], documented the resident received a diuretic medication seven out of seven days during the review period. A care plan, reviewed 03/02/23, did not document Res #21's diuretic use. On 03/29/23 at 1:59 p.m., the LTC MDS coordinator stated Res #21's care plan did not include the diuretic. She stated the diuretic should have been in the care plan.
- Potential for harm · D2023-03-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure one (#39) of five residents observed during med pass had an accurate medication reconciliation count. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: 1. A physician order for Res #49, dated 03/22/23, documented morphine 10 mg/ml administer 0.25 ml sublingual daily. On 03/29/23 at 8:45 a.m., CMA #1 was observed during medication pass. CMA #1 notified RN #1 there was an error on the narcotic count sheet. The narcotic count sheet documented 12 syringes of morphine remaining. The medication cart contained 13 syringes of morphine. On 03/29/23, at 9:00 a.m., RN #1 called the DON to the medication cart due to the discrepancy with the morphine for Res #49. The DON stated the night shift CMA had documented the medication as given but did not administer the morphine. The DON stated the omission of the morphine was a medication error.
- Potential for harm · D2023-03-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor one (#56) of five sampled residents for uneccessary medications. The Resident Census and Conditions of Residents report documented 14 residents were taking an antipsychotic medication. Findings: Res #56 was re-admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance. A care plan, dated 01/25/23, contained no documentation of revision to monitor for side effects of the medication. A physician order, dated 03/14/23, documented Olanzapine (an anti-psychotic medication) 2.5mg daily in the mornings. There was no documentation of side effect monitoring found in the medical record. On 03/29/23 at 9:18 a.m., MDS #1 was asked if the resident care plan should have been revised for the anti-psychotic medication. She reported yes it should have already been done. On 03/30/23 at 12:42 p.m., the DON reported the medication should have been monitored for side effects.
- Potential for harm · Dcited before2023-03-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on observation and interview, it was determined the facility failed to ensure: a. medications were labeled and b. expired mediations were removed from the medication storage room. This had the potential to affect all 78 residents who resided in the facility. Findings: On 03/30/23 at 8:17 a.m., a tour of the medication storage room was conducted with the ADON. The following medications were found with no label or direction for administration: a. one bottle of Acidophilus with Pectin Probiotic, and b. three acetaminophen suppositories 650mg. The following expired medications were found: a. three acetaminophen suppositories 650mg with an expiration date 02/04/23, b. one multi-dose vial of Tuberculin Purified Protein with no open date on the bottle or box, and c. two multi-dose vial of Influenza vaccine with no open date on the bottle or box. On 03/30/23 at 8:25 a.m., the ADON was asked if the expired medications should have already been removed. She stated, Yes. The ADON was asked if all the medications were supposed to be labeled. She stated, Yes.
- Potential for harm · D2023-03-30 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide food that accommodated resident allergies for one (#17) of two residents reviewed for dining. The Resident Census and Conditions of Residents documented 76 residents received services from the kitchen. Findings: A physician order, dated 03/28/21, documented Res #17 was to receive a regular diet with regular texture. The order did not document the resident's allergy. The EHR documented the resident's allergies were onions and Betadine. An emergency room visit summary, dated 04/21/21, documented Res #17 was seen for an allergic reaction. The summary documented a diagnosis of food allergy. A quarterly MDS, dated [DATE], documented Res #17 was cognitively intact and was independent with eating. A menu for 03/26/23 through 04/01/23, documented the dinner for Sunday 03/26/22 included onion rings. On 03/27/23 at 12:40 p.m., Res #17 stated he was allergic to onions and had received them on his meal tray at times. He reported having…
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.
“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.
- 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.
Fines & penalties
$16,430 in federal fines across 1 penalty.
- $16,430 — penalty dated 2025-09-18
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RIVERS EDGE OPERATIONS II LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2023 |
| OELBAUM, YITZCHOK | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 15% | since 09/01/2023 |
| AUBREY, CHRISTY | Individual | W-2 MANAGING EMPLOYEE | — | since 09/01/2023 |
| GANZ, DAVID | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2023 |
CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
About 71% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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
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.
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 375493. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-18, 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.