Cycle 1
Health 2024-08-14 · Fire 2024-08-14
28 health deficiencies
Top issue: Resident Assessment and Care Planning (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chandler, OK
Chandler Therapy & Living Center LLC
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $283,921 in total fines with 28 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
601 West 1st Street, Chandler, OK
(405) 785-7486
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-08-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.91
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.32
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
5.43
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.75% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 26 · Observed rate 11.54% · Lower 95% interval 6.51% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 56 |
| Staff flu vaccination coverage | 5.62% |
42%
36.4 pts worse
|
Numerator 5 · Denominator 89 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.3
0.5 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.4 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.1 |
2.9
2.2 pts worse
|
1.8
3.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.1 · Observed 6.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
90.3%
8.5 pts worse
|
93.4%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 84.6% · Q3 78.1% · Q4 75.0% · 4Q avg 81.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.0% |
94.6%
14.6 pts worse
|
95.5%
15.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
4.5%
0.6 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.1% · Q3 6.2% · Q4 3.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
3.3%
0.3 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q3 0.0% · Q4 6.9% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.6%
2.6 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
25.3%
1.3 pts better
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 21.4% · Q3 20.0% · Q4 28.0% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
18.6%
4.5 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.0% |
15.5%
5.5 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
14.1%
1.6 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 8.3% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.1%
1.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.8%
2.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.9% |
17.8%
3.9 pts better
|
19.8%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 23.9% · Q3 12.3% · Q4 13.2% · 4Q avg 13.9% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.1%
0.6 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.5% · Q3 3.1% · Q4 5.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.7% |
75.0%
8.3 pts worse
|
81.7%
15 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 66.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-17 · Fire 2023-07-17
18 health deficiencies
Top issue: Administration (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-04-06 · Fire 2022-04-06
23 health deficiencies
Top issue: Nutrition and Dietary (7 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-08-14
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-08-14
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-03
F · Potential for more than minimal harm
2022-04-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-06-23
F · Potential for more than minimal harm
2022-04-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-05-31
F · Potential for more than minimal harm
2022-04-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-31
F · Potential for more than minimal harm
2022-04-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-05-31
F · Potential for more than minimal harm
2022-04-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-11
F · Potential for more than minimal harm
2022-04-06
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-05-11
F · Potential for more than minimal harm
2022-04-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-11
F · Potential for more than minimal harm
2022-04-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-06-23
E · Potential for more than minimal harm
2022-04-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-11
E · Potential for more than minimal harm
2022-04-06
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-21
E · Potential for more than minimal harm
2022-04-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-05-21
E · Potential for more than minimal harm
2022-04-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-04-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-04-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-04-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-05-21
C · Minimal harm
2022-04-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-05-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-19
D · Potential for more than minimal harm
2025-12-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-19
F · Potential for more than minimal harm
2025-03-13
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-10
F · Potential for more than minimal harm
2025-03-13
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-03-13
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-03-13
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-13
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-10
E · Potential for more than minimal harm
2024-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-30
G · Actual harm
2024-08-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-01-04
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-02-02
E · Potential for more than minimal harm
2024-01-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-02
G · Actual harm
2023-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-18
K · Immediate jeopardy
2023-07-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-31
K · Immediate jeopardy
2023-07-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-07-17
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-07-17
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-07-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-05-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-05-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-05-18
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-05-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-05-18
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-05-18
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-07-31
J · Immediate jeopardy
2022-04-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-31
F · Potential for more than minimal harm
2022-04-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-04-06
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-06-10
E · Potential for more than minimal harm
2022-04-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-06-10
E · Potential for more than minimal harm
2022-04-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-10
E · Potential for more than minimal harm
2022-04-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-10
E · Potential for more than minimal harm
2022-04-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-04-06
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-05-31
Penalties and ownership
What sits behind the stars
$53,957
2024-08-10
Fine
Fine · fine $53,957
Fine
$0
2024-08-10
Payment Denial
Payment Denial · denial start 2024-09-21 · 9 days
9 day denial
$4,587
2023-11-13
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-06
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-30
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-23
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-17
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-10
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-02
Fine
Fine · fine $4,587
Fine
$4,587
2023-09-25
Fine
Fine · fine $4,587
Fine
$4,587
2023-09-18
Fine
Fine · fine $4,587
Fine
$4,587
2023-09-11
Fine
Fine · fine $4,587
Fine
$4,587
2023-09-05
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-28
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-21
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-14
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-07
Fine
Fine · fine $4,587
Fine
$13,762
2023-07-17
Fine
Fine · fine $13,762
Fine
$4,587
2023-06-26
Fine
Fine · fine $4,587
Fine
$4,235
2023-06-20
Fine
Fine · fine $4,235
Fine
$3,882
2023-06-12
Fine
Fine · fine $3,882
Fine
$3,529
2023-06-05
Fine
Fine · fine $3,529
Fine
$3,176
2023-05-30
Fine
Fine · fine $3,176
Fine
$2,823
2023-05-23
Fine
Fine · fine $2,823
Fine
$116,345
2023-05-18
Fine
Fine · fine $116,345
Fine
$0
2023-05-18
Payment Denial
Payment Denial · denial start 2023-08-18 · 74 days
74 day denial
$2,470
2023-05-15
Fine
Fine · fine $2,470
Fine
$2,117
2023-05-08
Fine
Fine · fine $2,117
Fine
$4,233
2023-04-17
Fine
Fine · fine $4,233
Fine
Ownership
Kilgore, Joshua
5% Or Greater Direct Ownership Interest · Individual
601ch, LLC
5% Or Greater Mortgage Interest · Organization
Dwuma, Alex
Operational/Managerial Control · Individual
Jones, Nola
Operational/Managerial Control · Individual
Kilgore, Joshua
Operational/Managerial Control · Individual
Nearby options
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#3
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1-star overall rating with 3-star inspections with 11 recent health deficiencies
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