Latimer Nursing Home
103 Southwest 9th Street, Wilburton, OK 74578 · For profit - Limited Liability company · 48 certified beds · (918) 465-2255 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $101,970 in federal fines (most recent 2024-01-22)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (59%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 27.5% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.5% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.7% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 9.2% | 2.8% | 2.0% | worse |
| 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 | 1.0% | 4.7% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.2% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 47.1% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.9% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.5% | 17.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.4% | 17.5% | 17.1% | typical |
* 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.
Staffing
How full it usually is: this home is certified for 48 beds and averages 28.6 residents a day — about 60% occupied, or roughly 19 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 4.44 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 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 4.74 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.31 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.
- Potential for harm · E2025-05-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide an environment free of urine odors for 1 of 2 halls. The Point of Care Rooms/Beds roster showed there were 14 residents residing on the South hall. Findings: On 05/05/25 at 12:30 p.m., there was a strong urine odor present on the South hall. On 05/06/25 at 7:50 a.m., there was a strong urine odor present on the South hall. On 05/07/25 at 7:55 a.m., there was a strong urine odor present on the south hall. On 05/07/25 at 4:07 p.m., LPN #3 stated in the morning the South hall smelled of urine. LPN #3 stated the odor got stronger when they opened the hopper room door. LPN #3 stated the strong urine smelled like the residents on the hall needed to drink more water. LPN #3 stated they provided water to all their residents and encouraged them to drink. On 05/07/25 at 4:29 p.m., CNA #3 stated the odor on the South hall was urine. CNA #3 stated they thought the strong urine odor was coming from one particular room. CNA #3 stated they changed the resident in that room and changed their linen, but even after cleaning 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 · E2025-05-13 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident received their pain medication as ordered by the physician for 1 (#20) of 1 sampled resident reviewed for narcotic pain medication use. The MDS coordinator identified 15 residents received narcotic pain medications. Findings: Resident #20's quarterly assessment, dated 03/24/25, showed Resident #20 was cognitively intact with a BIMS score of 15 and had diagnoses which included multiple sclerosis and chronic pain. Physicians orders, dated 03/26/25, showed Resident #20 was to receive: a. hydrocodone/acetaminophen (narcotic pain reliever) 10/325 mg, Give one tablet every six hours; b. cyclobenzaprine (muscle relaxant) 10 mg. Give one tablet in the morning, afternoon, and at bedtime; c. ibuprofen (nonsteroidal anti-inflammatory drug) 600 mg. Give one tablet every six hours as needed for pain; and d. Voltaren arthritis pain gel 1%. Administer topical every four hours as needed. A May 2025 medication administration record showed Resident #20 did not receive their hydrocodone/acetaminophen on 05/11/25 at 12:00…
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 before2025-05-13 · tag F0880 — failed to prevent and control infections — patternProvide 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 utilize EBP for 1 (#21) of 1 resident who was observed to receive catheter care. The Matrix for Providers identified three residents with urinary catheters. Findings: On 05/05/25 at 1:13 p.m., Resident #21 was observed in bed with a catheter bag hooked to the side of the bed. There was no sign to utilize enhanced barrier precautions nor was there enhanced barrier precaution equipment visible near the entrance to the resident's room or in the resident's room. On 05/08/25 at 2:50 p.m., CNA #4 was observed to drain the resident's urinary catheter. There was a towel, washcloth, and gloves lying on the floor near the foot of the resident's bed. CNA #4 was observed to remove gloves from their pocket, don gloves, kneel in front of the urinary catheter drainage bag, pull the towel and wash cloth from the foot of the bed and position the towel under the urinary drainage bag. CNA #4 removed the drainage tube and drained the urine from the bag into a used urinal. CNA #4 wiped the drainage tube with the wash cloth lying…
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 · D2025-05-13 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 ensure an admission resident assessment was completed within the required timeframe for 1 (#126) of 12 sampled residents whose resident assessments were reviewed. The administrator identified 27 residents resided in the facility. Findings: An admission assessment, dated 01/20/25, showed Resident #126 admitted on [DATE]. The assessment was signed as completed on 04/14/25. The assessment should have been completed by the resident's fourteenth day in the facility. On 05/07/25 at 2:08 p.m., the MDS coordinator stated the admission resident assessment was not completed timely. They stated the assessment dated [DATE] was not competed until 04/14/25.
- Potential for harm · D2025-05-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents were assisted with incontinent care for 1 (#20) of 1 sampled resident reviewed for ADL care. The administrator identified 27 residents resided in the facility. Findings: On 05/05/25 at 1:39 p.m. CNA #1 was observed to assist Resident #20 with incontinent care. Resident #20's brief was observed to be very saturated with dark yellow substance. There was a very strong urine odor in the room. An undated policy titled Behavioral Programs and Toileting Plans for Urinary Incontinence, read in part, A 'check and change' strategy involves check the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort to protect the skin. Resident #20's quarterly assessment, dated 03/24/25, showed the resident was cognitively intact with a BIMS score of 15 and had diagnoses which included multiple sclerosis and urinary incontinence. The assessment showed Resident #20 was totally dependent upon staff for assistance with all 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 · Fcited before2024-05-03 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed develop, implement a policy and procedure for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. The administrator identified 23 residents who resided in the facility. Findings: There was no policy and procedure for Legionella and other opportunistic waterborne pathogens in the building water system. On 05/03/24 at 10:16 a.m., the maintenance man stated the facility did not have a policy and procedure for Legionella at this time, but they were working on writing a policy and procedure for Legionella and other waterborne pathogens for the facility.
- Potential for harm · Ecited before2024-05-03 · tag F0578 — failed to honor advance directives / code status — patternHonor 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 residents were offered the choice to formulate advanced directives for three (#17, 20 and #25) of six sampled residents reviewed for advanced directives. The administrator identified 23 residents residing in the facility. Findings: 1. Res #17 was admitted with diagnoses which included hypertension and diabetes. There was no advance directive or advance directive acknowledgement in Res #17's electronic health record or paper chart. 2. Res #20 was admitted with diagnoses which included diabetes. There was no advance directive or advance direcgtive acknowledgement in Res 20's electronic health record or paper chart. The ADON was unable to provide documentation Res #17 and #20 had been offered the choice to formulate an advance directive. 3. Res. #25 was admitted to the facility with diagnoses including convulsions, peripheral vascular disease, anemia, and anxiety disorder. An admission assessment, dated 01/10/24, documented the resident was cognitively intact and maximum assist with showering and dressing the upper…
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 before2024-05-03 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure resident assessments were accurate for three (#2, 5, and #16 ) of 14 sampled residents whose resident assessments were reviewed for accuracy. The administrator identified 23 residents who resided in the facility. Findings: 1. Res #2 was admitted to the facility with diagnoses of diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, heart failure. A quarterly assessment, dated 01/22/23, documented the resident was cognitively intact and dependent on most ADLs. This assessment also documented the resident was taking an anti-anxiety and anit-depressive medications. On 02/07/24, a physician's order, documented bupropion 100 mg, give one tab by mouth daily for depressive disorder. On 05/03/24 at 11:16 a.m., the ADON/MDS Coordinator stated the resident was only taking antidepressive medication and they marked anti-anxiety by mistake. 2. Res #5 was admitted to the facility with diagnoses of transient cerebral ischemic attack, HTN, convulsions, injury of kidney, and depressive disorder. 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.
- Potential for harm · E2024-05-03 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to implement a comprehensive care plan: a. for five (#6, 8, 10, 16, and #25) of five reviewed for bedrails, b. for one (#13) of one reviewed for hospice care, c. for two (#2 and #13) of two reviewed for respiratory care, and d. for three (#13, 16, an #21) of 4 reviewed for unnecessary medications. The administrator identified 23 residents who resided in the facility. Findings: A. Bedrails 1. Res #6 was admitted to the facility with diagnoses of cerebral palsy, chronic pain syndrome, anxiety disorders, and cardiomegaly. A quarterly assessment, dated 03/01/24, documented the resident was cognitively intact and required total assistance with all ADLs. On 04/30/24 at 9:51 a.m., an observation was made of the resident lying in their bed with bedrails on each side of the bed. On 05/02/24 at 8:36 a.m., CNA #3 stated the resident cannot remove or lower the bedrails but they do use them to help roll from side to side. On 05/03/24 at 1:08 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-03 · 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
Based on observation, record review, and interview, the facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side- rails for (#6, 8, 9, 10, 13, 16, 17, and #25) of eight residents reviewed for accident hazards. The administrator identified 23 residents residing in the facility. Findings: A restraints policy, written in by hand and read in part, .6. Full bedrails/siderails (assist rails or ½ rails is not restraints) NO RESTRAINT WITH LOCKING DEVICEs WILL BE USED. NOTE: Restraing assessment will be done prior to use . 1. Res #6 was admitted to the facility with diagnoses of cerebral palsy, chronic pain syndrome, anxiety disorders, and cardiomegaly. A quarterly assessment, dated 03/01/24, documented the resident was cognitively intact and required total assistance with all ADLs. On 04/30/24 at 09:51 a.m., an observation was made of the resident lying in their bed with bedrails on each side of the bed. On 05/02/24 at 8:36 a.m., CNA #3 stated the resident cannot remove or lower the bedrails but they do use them to help…
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 11 citations
- Potential for harm · E2024-05-03 · 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
Based on record review and interview, the facility failed to ensure a consultant pharmacist reviewed the medications of each resident in the facility monthly for four (#2, 10, 16, and #21) of five sampled residents reviewed for unnecessary medications. The administrator identified 23 residents who resided in the facility. Findings: 1. Res #2 was admitted to the facility with diagnoses of diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure. A quarterly assessment, dated 11/22/23, documented the resident was cognitively intact and dependent on most ADLs. This assessment also documented the resident was taking antianxiety, antidepressants, and diuretics. 2. Res #10 was admitted to the facility with diagnoses of fracture of hip, malaise, multiple sclerosis, history or schizophrenia, convulsions, atrial fibrillation, and mood disorder. An annual assessment, dated 12/14/23, documented the cognitive with daily decision making and independent with all ADLs. The assessment also documented the resident was taking antipsychotics 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 · E2024-05-03 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 ensure medication cards were labeled appropriately with an expiration date for 49 of 55 sampled medication cards. The administrator identified 23 residents who resided in the facility. Findings: The labeling of medications policy, undated, read in part, .ALL PRESCRIPTION MEDICATIONS WILL HAVE THE FOLLOWING LABELING REQUIREMENTS SATISFIED: .To every box, bottle, jar, tube or other container of a prescription legend med which is dispensed, there shall be affixed a label bearing: .the expiration of the medication. On 05/02/24 at 2:40 p.m., the medication cart for female residents was inspected with 30 of 34 medication card labels to have no expiration date. The expiration date at the bottom of the label is cut off or cannot be read. On 05/02/24 at 2:50 p.m., the medication cart for male residents was inspected with 19 of 21 medication card labels to have no expiration date. The expiration date at the bottom of the label is cut off or cannot be read. On 05/02/24 at 2:51 p.m., CMA #1 was unable to read the expiration date on 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 · E2024-05-03 · 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 — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to serve food under sanitary conditions for 23 residents who ate meals prepared by the kitchen. The administrator identified 23 residents who resided in the facility. Findings: On 05/02/24 at 12:12 p.m., the dietary manager was observed serving lunch trays to the residents in the dining room wearing gloves. The dietary manager would exit the kitchen with a food tray wearing gloves, place the food tray on the table for the resident in the dining area, and then enter the kitchen again to collect another food tray for another resident. The dietary manager did this several times wearing the same set of gloves and without proper hand washing in between residents. On 05/02/24 at 12:23 p.m., the dietary manager stated they thought if they were wearing gloves they could exit and enter the kitchen without washing their hands to serve the residents in the dining area. They also stated they would begin handing the food trays to the aides without leaving the kitchen so they would not cross-contaminate from the kitchen to the dining area.
- Potential for harm · E2024-05-03 · 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, interview, and record review, it determined the facility failed to ensure regular inspections of resident beds equipped with side rails were conducted for eight (#6, 8, 9, 10, 13, 16,17, and #25) of eight residents reviewed for accident hazards. The administrator identified 23 residents residing in the facility. Findings: 1. Res #6 was admitted to the facility with diagnoses of cerebral palsy, chronic pain syndrome, anxiety disorders, and cardiomegaly. A quarterly assessment, dated 03/01/24, documented the resident was cognitively intact and required total assistance with all ADLs. On 04/30/24 at 09:51 a.m., an observation was made of the resident lying in their bed with bedrails on each side of the bed. On 05/02/24 at 8:36 a.m., CNA #3 stated the resident cannot remove or lower the bedrails but they do use them to help roll from side to side. On 05/03/24 at 1:08 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 2. Res #8 was admitted to the facility with diagnoses of multiple fractures…
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 · D2024-05-03 · 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 — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure a resident was treated with dignity during a transfer for one (#1) of one sampled resident observed for dignity. The administrator identified 23 residents residing in the facility. Findings: Res #1 Res #1 was admitted to the facility with cerebral brain stem hemorrhage without loss of consciousness, anxiety disorder, and depression disorder. A quarterly assessment, dated 04/12/24, documented the resident had problems with short- and long-term memory and required total assistance with most ADL's. On 05/02/24 at 9:17 a.m., an observation was made of CNA # 3 transporting Res #1 to their room from the shower room exposing their body to those in the hallway. On 05/02/24 at 9:18 a.m. CNA #3 stated they should have utilized two sheets to cover Res #1 lower part of her body. They also stated they did not notice the lower part of the Res #1 body was even exposed while transporting the Res #1 in the hallway.
- Potential for harm · D2024-05-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to revise a care plan for one (#11) of nine sampled residents whose care plans were reviewed for accuracy. The administrator identified 23 residents who resided in the facility. Findings: Res #11 had diagnoses which included peripheral vascular disease and a right above the knee amputation. Res #11's care plan, dated 02/23/24, documented Res #11 has the potential for skin issues. The care plan was not revised when Res #11 developed their right stump wound. A physician's order, dated 03/26/24 documented a wound care treatment of silvadene cream to Res #11's right stump daily. On 05/02/24 at 10:05 a.m., observed Res #11's wound care treatment to their right stump wound. On 05/03/24 at 11:40 a.m., the MDS Coordinator reported the care plan should have been revised when Res #11 developed a right stump wound. The MDS Coordinator reported they are new to the position and still learning care plans and what should be care planned.
- Potential for harm · D2024-05-03 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 document a recapitulation of a resident's stay on a discharge summary for one (#26) of two sampled residents whose closed records were reviewed. The administrator identified 23 residents who resided in the facility. Findings: Res #26 was admitted on [DATE] and discharged to another facility on 02/05/24. There was no recapitulation of Res #26's stay in the facility on the discharge summary. On 05/03/24 at 12:15 p.m., the MDS Coordinator/ADON reported they recently received an example of how a discharge summary should be documented and reported they will be documenting a recap of the resident's stay going forward.
- Potential for harm · D2024-05-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 develop and implement physician's orders for oxygen tubing care maintenance for two (#2 and #13) of two resident sampled for oxygen therapy. The administrator identified 23 residents residing in the facility. Findings: A document titled, Orientation of Residents to the Facility, read in part, .Oxygen Administration .Procedure .12. At regular intervals, check and clean oxygen equipment, masks, tubing, and cannula's . 1. Res #2 was admitted to the facility with diagnoses of diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure. A quarterly assessment, dated 11/22/23, documented the resident was cognitively intact and dependent on most ADLs. This assessment also documented the resident was on oxygen. There were no physician orders to check and clean oxygen equipment, masks, tubing, and/or cannula's. 2. Res #13 was admitted to the facility with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease. A significant change assessment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-23 · tag F0578 — failed to honor advance directives / code status — widespreadHonor 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure residents were informed and provided written information concerning the right to accept or refuse to formulate an advance directive. The Resident Census and Conditions of Residents, dated 03/21/23, documented a census of 27 residents. Findings: A review of the facility's policies failed to show implementation of a policy for advance directives. A review of records failed to show written advanced directive information had been provided to residents. On 03/22/23 at 4:00 p.m., the DON reported they were unaware of the requirement to inform and provide written information to residents regarding the right to accept or refuse to formulate an advance directive.
- Potential for harm · Dcited before2023-03-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure resident assessments were accurate for a resident with gradual dose reduction for one (#8) of one resident reviewed for antipsychotic medication and for a resident with behaviors for one (#10) of one resident reviewed for behaviors. A Roster Sample Matrix, dated 03/21/23, documented six residents were taking antipsychotic medications. The Resident Census and Conditions of Residents, dated 03/21/23, documented a census of 27 residents. Findings: Res #8 was admitted with diagnoses which included paranoid schizophrenia A physician's order for a gradual dose reduction, dated 01/26/23, read in part, Decrease Seroquel 50mg 1 PO BID. A quarterly assessment, dated 03/04/23, read in parts, .has a gradual dose reduction been attempted? No . On 03/23/23 at 1:10 p.m., the MDS Coordinator reported the gradual dose reduction for Res #8 on 01/26/23 should have been documented on the assessment for 03/04/23. Res #10 was admitted with diagnoses which included dementia with behavioral disturbances. A nursing note, dated 03/04/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-23 · 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 record review and interview, the facility failed to document a change in condition for one (#1) of one resident reviewed for a change in condition and obtain physician's orders for diabetic interventions for one (#4) of two residents reviewed for diabetes. A Roster Sample Matrix, dated 03/21/23, documented four residents were insulin dependent diabetics. The Resident Census and Conditions of Residents, dated 03/21/23, documented a census of 27 residents. Findings: Res #1 was admitted with diagnoses which included traumatic brain injury. A statement by RN #1, dated 03/25/21, read in parts, 11-7 shift 3-21-21 .called to Res #1's room .Res #1 is sitting on the bedside commode, restless, confused, diaphoretic FSBS results 458mg/dl .called Dr (name withheld) .informed Dr Res #1 does not have a Dx of diabetes .is diaphoretic, confused and restless .received V/O to give Novolog (insulin to lower blood sugar) 10u now, recheck FSBS in 1 hour and to get Hgb A1C (a lab test to monitor blood sugar) in the am .0134 FSBS 92mg/dl .pleasantly confused .L wrist with edema and looks out 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.
“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
$101,970 in federal fines across 18 penalties.
- $14,679 — penalty dated 2024-01-22
- $4,893 — penalty dated 2024-01-08
- $4,545 — penalty dated 2024-01-02
- $13,635 — penalty dated 2023-12-11
- $4,587 — penalty dated 2023-11-20
- $4,587 — penalty dated 2023-11-13
- $4,587 — penalty dated 2023-11-06
- $4,587 — penalty dated 2023-10-30
- $4,587 — penalty dated 2023-10-23
- $4,587 — penalty dated 2023-10-17
- $4,587 — penalty dated 2023-10-10
- $4,587 — penalty dated 2023-10-02
- $4,587 — penalty dated 2023-09-25
- $4,587 — penalty dated 2023-09-18
- $4,587 — penalty dated 2023-09-11
- $4,587 — penalty dated 2023-09-05
- $4,587 — penalty dated 2023-08-28
- $4,587 — penalty dated 2023-08-21
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 |
|---|---|---|---|---|
| TIDWELL, DARREN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 01/22/2025 |
| TIDWELL, MELISSA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 11/01/2023 |
| TIDWELL, PARKER | Individual | W-2 MANAGING EMPLOYEE | — | since 07/11/2023 |
CMS files one row per role, so the 6 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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 89% 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 375535. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-13, 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.