Cycle 1
Health 2024-07-11 · Fire 2024-07-11
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Wakita, OK
Community Health Center
2-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1153 Cherokee Street, Wakita, OK
(580) 594-2292
Overall
2 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
35
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-10-23
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
0.47
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,919
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0077
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.79
Baseline 46.88% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 2.62
Adjusted total nurse staffing
4.81
Baseline 4.63 hours · Performance 4.45 hours · Measure score 4.81 · Achievement 4.81 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 1 · 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 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.64% |
8.2%
4.6 pts worse
|
Numerator 2 · Denominator 55 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 1 · 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 Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.3
0.1 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.3 · Expected 1.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.9
0.8 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 2.5 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.2% |
90.3%
9.1 pts worse
|
93.4%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.5% · Q2 69.7% · Q3 87.9% · Q4 90.9% · 4Q avg 81.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
94.6%
0.1 pts better
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
4.5%
3 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 3.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
3.3%
0.9 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 3.3% · Q4 3.2% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
3.6%
1.8 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 3.8% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.8% |
25.3%
6.5 pts worse
|
19.6%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 32.1% · Q3 29.6% · Q4 29.6% · 4Q avg 31.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
18.6%
1 pts worse
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 16.7% · Q3 17.4% · Q4 17.4% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.5% |
0.1%
1.4 pts worse
|
0.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.1% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.5% |
15.5%
9 pts worse
|
16.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.0% |
14.1%
18.9 pts worse
|
14.9%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 30.8% · Q3 44.0% · Q4 37.5% · 4Q avg 33.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
2.1%
0.7 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 3.3% · Q4 2.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.8%
0.5 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 6.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
17.8%
4.5 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 9.3% · Q3 28.5% · Q4 22.3% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.1%
1.1 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.1% · Q3 7.4% · Q4 2.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 40.0% |
75.0%
35 pts worse
|
81.7%
41.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 40.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-27 · Fire 2023-06-27
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-06-09 · Fire 2021-06-09
26 health deficiencies
Top issue: Resident Rights (8 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-11
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 2024-08-07
E · Potential for more than minimal harm
2024-07-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-07
E · Potential for more than minimal harm
2023-06-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-06-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-06-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-20
E · Potential for more than minimal harm
2021-06-09
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 2021-07-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-11
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-01-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-20
F · Potential for more than minimal harm
2021-06-09
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2021-06-10
F · Potential for more than minimal harm
2021-06-09
F564 · Resident Rights Deficiencies
Health
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Corrected 2021-08-01
F · Potential for more than minimal harm
2021-06-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-08-01
F · Potential for more than minimal harm
2021-06-09
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 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
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 2021-08-01
E · Potential for more than minimal harm
2021-06-09
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 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
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 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
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 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-01
E · Potential for more than minimal harm
2021-06-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2021-08-01
Penalties and ownership
What sits behind the stars
Ownership
Jones, Alvin
Operational/Managerial Control · Individual
Lanie, Randy
Corporate Director · Individual
Mitchell, Peggy
Operational/Managerial Control · Individual
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