Cycle 1
Health 2024-04-25 · Fire 2024-04-25
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Duncan, OK
Elk Crossing
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
811 West Elk, Duncan, OK
(580) 475-0750
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-01-04
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
0.29
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
4.35
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
5.88
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
5.19
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
6.48
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,193
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.11
Composite VBP score used to determine payment impact.
Payment multiplier
1.0054
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.63
Baseline 17.80% · Performance 19.29% · Measure score 4.63 · Achievement 4.63 · Improvement 0
Healthcare-associated infections
2.14
Baseline 7.46% · Performance 7.20% · Measure score 2.14 · Achievement 2.14 · Improvement 0.58
Total nurse turnover
3.68
Baseline 49.62% · Performance 48.65% · Measure score 3.68 · Achievement 3.68 · Improvement 0
Adjusted total nurse staffing
10
Baseline 6.41 hours · Performance 6.11 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.29% |
10.72%
2.6 pts worse
|
Worse than the National Rate · Eligible stays 356 · Observed rate 14.33% · Lower 95% interval 10.78% |
| Discharge to community | 63.28% |
50.57%
12.7 pts better
|
Better than the National Rate · Eligible stays 324 · Observed rate 58.95% · Lower 95% interval 56.55% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.61% |
95.27%
4.3 pts better
|
Numerator 255 · Denominator 256 |
| Falls with major injury | 1.95% |
0.77%
1.2 pts worse
|
Numerator 5 · Denominator 256 |
| Discharge self-care score | 74.47% |
53.69%
20.8 pts better
|
Numerator 140 · Denominator 188 |
| Discharge mobility score | 69.15% |
50.94%
18.2 pts better
|
Numerator 130 · Denominator 188 |
| Pressure ulcers or injuries, new or worsened | 1.95% |
2.29%
0.3 pts better
|
Numerator 5 · Denominator 256 · Adjusted rate 2.14% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 215 · Observed rate 6.51% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | 5.58% |
8.2%
2.6 pts worse
|
Numerator 12 · Denominator 215 |
| Staff flu vaccination coverage | 10.69% |
42%
31.3 pts worse
|
Numerator 31 · Denominator 290 |
| Discharge function score | 69.68% |
56.45%
13.2 pts better
|
Numerator 131 · Denominator 188 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 180 · Denominator 180 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 15.08% |
25.2%
10.1 pts worse
|
Numerator 19 · Denominator 126 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.3
0.7 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.9
0.3 pts better
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.3%
9.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| 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 2.9% · Q2 5.0% · Q3 6.0% · Q4 6.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.3%
3.3 pts better
|
11.4%
11.4 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 who lose too much weight | 0.9% |
3.6%
2.7 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.7% |
25.3%
9.4 pts worse
|
19.6%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.6% · Q2 37.3% · Q3 31.2% · Q4 31.8% · 4Q avg 34.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.9% |
18.6%
3.7 pts better
|
16.7%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 20.0% · Q3 14.3% · Q4 14.3% · 4Q avg 14.9% · 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 | 23.6% |
15.5%
8.1 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 28.3% · Q3 39.2% · Q4 11.9% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
14.1%
1.3 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 18.6% · Q3 18.8% · Q4 6.1% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.1%
2.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.8%
1.1 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 2.5% · Q4 2.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
17.8%
1.6 pts worse
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 18.8% · Q3 18.0% · Q4 18.1% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.1%
2 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.8% · Q3 3.7% · Q4 2.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
75.0%
24.4 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.2% · Q4 98.4% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
17.1%
0.5 pts better
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 15.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.9%
1.3 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
74.0%
22.7 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
27.0%
1.1 pts better
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 23.3% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-23 · Fire 2023-03-23
2 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-04-28 · Fire 2021-04-28
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-04-25
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 2024-06-10
D · Potential for more than minimal harm
2024-04-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-31
E · Potential for more than minimal harm
2023-03-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-03-23
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-06-15
Penalties and ownership
What sits behind the stars
Ownership
Gregston, Jeff
5% Or Greater Direct Ownership Interest · Individual
Greiner, Kenneth
5% Or Greater Direct Ownership Interest · Individual
Miller, Douglas
5% Or Greater Direct Ownership Interest · Individual
Gregston, Jeff
Corporate Officer · Individual
Stewart, Bethany
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Wilkins Health & Rehabilitation Community
Duncan, OK
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Meridian Nursing Home
Comanche, OK
4-star overall rating with 5-star inspections
#3
Gregston Nursing Home, Inc.
Marlow, OK
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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